Inquest into death of vulnerable woman at HMP Styal finds “unacceptable” delay in cell bell response contributed to death
CONTENT WARNING: This article contains themes of self-inflicted harm.
On Monday 9 November, an inquest jury in Warrington concluded that the self-inflicted death of a vulnerable woman in prison was contributed to by the “unacceptable delay” in answering her emergency call bell.
Stephanie Brennan was detained at HMP Styal on 8 March 2025 when a failure to facilitate her attendance at a salon appointment led to an escalating emotional response, recorded through phone calls to her partner. After she activated her emergency call bell for the last time at 10:50am, it went unanswered for 1 hour and 15 minutes despite the fact that prison policy required it to have been responded to within five minutes. Stephanie was then found to have ligatured in her cell and died the following day in hospital.
The jury found that Stephanie had been “optimistic” before her release, but due to an “ineffective” movement list process, a process intended to enable prisoners to attend appointments in the prison, she was not escorted to her salon appointment which negatively impacted her mental health. The jury were “doubtful” that the prison officers had adequate experience to effectively implement the restricted regime in place on the day, which resulted in an “unacceptable delay” in responding to Stephanie’s call bell of 1 hour and 15 minutes.
The Coroner confirmed that she would be making a Prevention of Future Deaths report regarding the emergency call bell system and issues surrounding the prison’s late disclosure of evidence to the court.
Events leading up to 8 March 2025
Stephanie Brennan was 38 years old when she died. She had a history of mental ill health including previous diagnoses of Paranoid Schizophrenia and Emotionally Unstable Personality Disorder, as well as trauma in her childhood and substance misuse issues. Stephanie’s family describe her as gentle, caring, and generous to a fault.
Stephanie was recalled to HMP Styal on 11 February 2025. She had previously been detained at HMP Styal for around 5 weeks from December 2024 to February 2025 for theft offences.
Stephanie consistently reported hearing voices while in prison, and requested an increase in her medication. On 25 February, she ended an appointment with a psychiatrist early after being told that her medication would not be increased. She did not have a further assessment.
On Saturday 8 March 2025, Stephanie had a salon appointment in the prison booked for 08:30am. She was two days away from being released from prison and was described as looking forward to getting out. On that day, limited availability of prison staff resulted in a decision to put her wing in a restricted regime, which meant there were only two prison officers and one supervising officer overseeing the wing.
The inquest heard that the emergency call bell button that prisoners could activate was their only way of communicating with officers on the wing when locked in their cells. Activating the bell caused a red light to flash outside the cell, and panels inside and outside the wing office would indicate that a call bell had been activated. The inquest heard that the system did not indicate how long a prisoner’s call bell had been triggered for or make any change to the noise or display to indicate that a bell had gone unanswered for longer than 5 minutes. One officer described the noise made by the cell bell system which was intended to alert them to an activated call bell as “constant background noise”. When asked about whether this was an effective system, the Head of Safer Prisoners at HMP Styal stated in her evidence that “there could be improvements made”.
Stephanie triggered her emergency call bell on six occasions on the morning of 8 March. She brought her missed salon appointment to the attention of both prison officers and the supervising officer on the wing. The inquest heard that the supervising officer had directed the male prison officer on the wing to follow up with the salon and find out what had happened with Stephanie’s appointment. The male prison officer denied that this conversation took place. No further steps were taken to resolve the issue with Stephanie’s salon appointment.
Stephanie’s mounting distress was recorded in phone calls to her partner, with recordings played for the inquest jury. Following the fifth activation of her emergency call bell, in her final two calls to her partner Stephanie can be heard in an extreme state of distress, screaming and banging on her cell door. She told her partner that her bell had been “on for ages and ages and ages and not one officer’s come”. Another prisoner, who knew Stephanie and described her as a “lovely person”, gave evidence that on that morning Stephanie had been “banging” on her cell and “asking for help”. She had seen Stephanie’s call bell light on and said other prisoners were “shouting saying ‘can you answer the call bells’”.
In their evidence to the inquest, all of the officers who had been working on the wing gave evidence that they had not heard Stephanie’s shouting or banging on her cell door. A senior prison witness stated that any such sound would “echo” around the wing and “absolutely” would have been audible to anyone on the same landing at Stephanie’s cell.
Around four minutes after her last call with her partner ended, Stephanie’s cell was visited by the female prison officer after another prisoner told her that Stephanie wanted to speak to her. By this time, Stephanie’s emergency call bell had been activated for 39 minutes. The female prison officer said that Stephanie had asked why she wasn’t taken to her appointment and “demanded” to speak to the supervising officer, following which the female prison officer responded that Stephanie could not demand to speak to a member of staff, and ended the conversation. She said she could not recall if Stephanie was distressed during this interaction.
Stephanie reactivated her emergency cell bell for the final time at 10:50am. Despite there being an accepted five-minute response time for prison officers to respond to emergency call bells, Stephanie’s emergency call bell was not responded to for 1 hour and 15 minutes. The female prison officer was seen on CCTV walking past Stephanie’s cell three times while Stephanie’s call bell had been activated, but failed to respond. All three officers denied having been aware that Stephanie’s call bell was activated during this period.
At 12:05pm, the male officer went to unlock Stephanie’s cell for lunch and discovered that she had ligatured. Despite CPR efforts, Stephanie died in hospital the following day. Unfortunately, her mother and step-father were not informed and they had to contact the prison themselves to confirm that she had died.
Stephanie’s death followed the tragic death of Alex Davies at HMP Styal less than 3 months earlier, whose self-inflicted death was found by an inquest jury to have been contributed to by neglect.
Bridgette Brennan and Jim Brennan, Stephanie’s mother and step-father, said:
“We loved our daughter and we miss her so much, we think about her every day and our lives will never be the same without her. Stephanie suffered with her mental health from when she was very young. She was a very vulnerable woman with diagnoses of Schizophrenia and EUPD that we feel were not properly addressed by prison healthcare.
Our daughter was asking for help and needed better support from prison staff and Mental Health Team. We feel that Stephanie was failed and neglected by the state. Any other establishment with Styal’s track record of deaths would be shut down. There needs to be a better system in place to hold prison officers accountable when they fail the people in their care.
Failings at HMP Styal have been well documented in the past. How many more vulnerable women will suffer the same fate as our daughter if the system does not learn from its mistakes and implement much needed change.
Our daughter is now a statistic on a long list. The prison should hang their heads in shame and remember that most women in prison are vulnerable victims of circumstance who are driven to substance misuse and mental ill health, and are often involved in crime through manipulation and coercion.”
Betty McCann, solicitor for Stephanie’s family, added: “Women’s prisons are not a safe place for vulnerable women. The tragedy of Stephanie’s death is how easily it could have been avoided. Instead, Stephanie’s family have had to deal with her devastating loss. The prison system is fundamentally not fit for purpose and Stephanie’s death reflects how crucial safeguards for prisoners like the emergency call bell system need to operate effectively, or otherwise risk devastating consequences.”
If you are feeling low, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
Notes for media: Please refer to the Samaritans guide on reporting inquests: https://www.samaritans.org/about-samaritans/media-guidelines/guidance-reporting-inquests/
ENDS
NOTES TO EDITORS
For further information and to note your interest, please contact Betty McCann of Deighton Pierce Glynn Solicitors, solicitor for the family: BMcCann@dpglaw.co.uk, 020 7407 0007
The family is represented by Betty McCann and Ceri Lloyd-Hughes of Deighton Pierce Glynn Solicitors and Kate Stone of Garden Court North Chambers. They are supported by INQUEST Caseworker Kate Litman.
Other Interested Persons represented are HMP Styal, two officers at the prison, Greater Manchester Mental Health NHS Foundation Trust, and Spectrum Community Health CIC.
A photo of Stephanie for media use is available here.
