A West Yorkshire lawyer is calling for urgent reviews into inmate safety for vulnerable individuals after the tragic and avoidable death of a young woman in prison.

An inquest held into the death of 21-year-old Emily Hartley returned a narrative verdict after she died at HMP New Hall, Flockton , in April 2016.

Ruth Bundey, a partner at Harrison Bundey in Leeds, was asked to represent Emily’s family in the proceedings by the charity INQUEST.

The inquest was held at Wakefield Coroners’ Court and overseen by David Hinchliff, the Senior Coroner for West Yorkshire, and with a jury sitting.

Ruth Bundey said: “This was Emily’s first time in prison. Her remand was against a background of serious mental ill health including self-harm, suicide attempts and drug addiction. Emily’s death was one of four at New Hall in 2016, at least three of which were self-inflicted.”

Emily Hartley who died at HMP New Hall, Flockton

As part of the suicide and self-harm management processes, Emily was meant to be observed at regular intervals. She continued to self-harm and frequently advised prison staff that she wished to take her own life.

Despite the obvious context, it was also deemed appropriate for Emily to be made subject to disciplinary procedures when dealing with her behaviour.

On April 23, 2016, Emily took her own life behind a building. It took two and a half hours for Emily to be found despite the fact that staff were meant to check on her wellbeing twice every hour.

Returning a narrative verdict, the inquest’s findings also concluded that the deterioration in Emily’s mental state should have prompted a review, and she should have been moved to a therapeutic unit; failures in the implementation of the implementation of suicide and self-harm procedures known as ACCT were a contributing factor in Emily’s death; the lack of professionalism shown by some staff could have been interpreted by Emily as bullying.

The staff in question gave contradictory evidence at the inquest, which led to an observation by the jury that it was ‘logically clear that fictional accounts were given under oath’, and finally, the exercise yard (where Emily died) was not fit for purpose. Risk assessments should have readily identified that prisoners could disappear from view.

New Hall prison, Flockton.

Ruth Bundey continued: “During her time in New Hall Emily struggled to cope with both prison and her mental health issues.

"Her behaviour had dramatically escalated eight days prior to her death when she used a ligature as well as showing a mental health nurse a ‘suicide file’ together with a letter for ‘who finds me.’ Knowledge of this file had not been properly shared among staff so adequate precautions could be taken or even stepped up.

“The jury’s assessment of Emily’s case, and its findings, are clear. Emily was failed by an inadequate system and a distinct lack of competence.

“Lessons must be learned from this tragic and totally avoidable death. At the very least, it is to be hoped that the jury’s findings are properly and thoroughly considered, leading to widespread changes and improvements not just at New Hall but across the entire prison estate.”

It is understood that several officers at New Hall were disciplined because of failings in Emily’s care.

Harrison Bundey is part of Ison Harrison, who have 11 offices across West Yorkshire including Huddersfield.

For more information visit https:// www.isonharrison.co.uk

Where to get help if you're struggling

You don't have to suffer in silence if you're struggling with your mental health. Here are some groups you can contact when you need help.

Samaritans: Phone 116 123, 24 hours a day, or email jo@samaritans.org, in confidence

Childline: Phone 0800 1111. Calls are free and won't show up on your bill

PAPYRUS: A voluntary organisation supporting suicidal teens and young adults. Phone 0800 068 4141

Depression Alliance: A charity for people with depression. No helpline but offers useful resources and links to other information

Students Against Depression: A website for students who are depressed, have low mood, or are suicidal. Click here to visit

Bullying UK: A website for both children and adults affected by bullying. Click here

Campaign Against Living Miserably (CALM): For young men who are feeling unhappy. Has a website and a helpline: 0800 58 58 58