Inadequate care at HMP Leeds contributed to the death of Vikki Thompson, who told prison staff she would ‘leave prison in a box’

Vikki was 21 years old and had been held on remand in HMP Leeds for less than a month when she died on 13 November 2015. Today, the jury at the two-week inquest into Vikki’s death concluded that she did not intend to take her own life. They also found that her treatment whist on remand in HMP Leeds was inadequate and lacked professionalism.

Inquest findings

• Throughout her life, Vikki was let down by various departments including the NHS, Leeds Community Healthcare NHS Trust and the prison
• The co-ordination and management of Vikki’s risk of self-harm in prison and the community by the NHS made more than minimal contribution to her death
• The management of Assessment, Care in Custody and Teamwork (ACCT) procedures for Vikki was inadequate and observations of Vikki’s cell paid only ‘lip service’ to the standard and frequency required
• The mandatory actions required by the (now replaced) PSI on “the care and management of transsexual offenders” were not complied with

The jury also recognised the day-to-day pressures on all services involved, which were under immense pressure, understaffed and working in extremely difficult situations.

Dr Mitchell, the Clinical Reviewer for the Prison and Probation Ombudsman, told the inquest that Vikki’s health and mental health care was not sufficient and “scant regard was given to her mental health and her transgender issues by healthcare staff.” Evidence of several issues with ACCT procedures included that no member of health care, mental health or equalities staff ever attended any of the ACCT meetings.

The jury heard Vikki told the first healthcare assistant she spoke to that she didn’t want to be in a men’s prison, yet this comment was neither recorded or raised with other prison or healthcare staff. As part of the case management plan, Vikki agreed with the prison that she would not add excessive padding to her bra and only wear make-up in moderation.

Multiple times, both in prison and before she was transferred from police custody, Vikki had told staff she would “be carried out in a box”. Whilst in HMP Leeds, she was subject to multiple incidents of sexual harassment, transphobic abuse and bullying.

HMP Leeds has the second highest rate of deaths in any prison in the UK. Over the past five years there have been 14 self-inflicted deaths at the prison. Ministry of Justice (MOJ) stats show the rate of self-inflicted deaths in prisons has more than doubled since 2013.

There have been two further deaths of transgender women in men’s prisons since Vikki died. Joanne Latham died in HMP Woodhill on 27 November 2015 (only weeks after Vikki). Jenny Swift died in HMP Doncaster on 30 December 2016.

These deaths, as well as a number of high profile battles for trans women to be transferred to women’s prisons, led to an Ministry of Justice review of the ‘Care and management of transgender offenders’. This led to the creation of a new Prison Service Instruction, which became active in January 2017. Clinks produced a briefing on the review.

Lisa Harrison, mother of Vikki Thompson said:

“Words cannot describe the upset of losing my daughter Vikki. She was such a bubbly personality and so full of life. As a transgender woman, she experienced a number of difficulties throughout her life. She was the victim of a rape and was going through the process of dealing with this not long before she was sent back to HMP Leeds. Vikki was anxious to be back in prison and repeatedly expressed her concerns.  I do not feel that the prison fully appreciated Vikki’s vulnerabilities and I believe their lack of insight has resulted in her death.”

Deborah Coles, Director of INQUEST said:

“This was a death waiting to happen. A vulnerable, young transgender woman was sent to a men’s prison despite the risks of abuse and mistreatment. There was little consideration of the gender she had openly identified with for half her life. Leeds prison has the second highest rate of self-inflicted deaths in the country. It was also a prison in which Vikki said she had previously been sexually assaulted, and where she was a victim of transphobic abuse and harassment.

Following the death of Vikki and Joanne Latham (both trans women in men’s prisons) the government implemented a new PSI which significantly improves the policy on the care and management of transgender prisoners. However, it remains to be seen how much of a difference this will make in practice.

We are not convinced that the new PSI could have prevented Vikki’s death, given the range of failures uncovered at this inquest. Vikki’s treatment by the prison and healthcare trust was at best incompetent and at worst inhumane. Recent inquests at HMP Leeds and other prisons have shown staff are unable to implement even the most basic training and policies intended to protect vulnerable prisoners. The incoming Government needs to address the unacceptable death toll in prisons and the high numbers of people in prison who should not be there at all.”

The family is represented by INQUEST Lawyers Group members Philip Goldberg and Gemma Vine of Minton Morrill Solicitors and Anna Morris of Garden Court Chambers' Inquests and Inquiries Team.

The inquest into Vikki’s death has received national press coverage, including in the Guardian and the BBC.

To view INQUEST’s press release, click here.

For further information and PR enquiries, please contact Natalie Rogers of Scala UK Ltd. To view Scala’s press release on behalf of Minon Morrill, please click here.

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