Overview
- Jurors recorded hanging as the cause of death and said her intention at the time could not be determined.
- The jury found a gross failure to place Davies on constant observations in the Care and Separation Unit, a lapse they said probably caused her death.
- A nurse told the inquest he completed a healthcare algorithm incorrectly, which would otherwise have flagged concerns about her CSU placement.
- National guidance discourages keeping people at suicide risk in segregation except in exceptional circumstances; Davies spent 27 days in the unit and was returned there on 24 December.
- The Prison Service acknowledged her care fell far short, cited immediate actions after the death, and said it will adopt forthcoming Ombudsman recommendations, as inspectors previously logged more than 5,200 self-harm incidents at Styal in a year.