A vulnerable and seriously mentally ill woman had her supervision reduced and was unable to access her anti-psychotic medication before she died in Holloway Prison, an inquest has heard.

Sarah Reed, 32, had been classed as at low risk of self-harm by prison healthcare staff. At the opening of the inquest into her death, assistant coroner for the City of London, Peter Thornton, told the jury that Reed developed serious mental health problems in 2003 after the death of her baby at the age of nine months from muscular atrophy.

She suffered from psychotic and hallucinatory episodes, was in and out of mental health wards and spent periods of time in prison. She suffered from schizophrenia, was emotionally unstable, had a personality disorder, used drugs and alcohol and suffered from bulimia, incidents of serious self-harm and threats to take her own life. She was sectioned and in mental health hospitals from time to time.

On 14 October 2015 she was remanded in custody for the purpose of getting psychiatric reports after being charged with assault in a psychiatric hospital where she was being cared for at the time. At the time of her death she was still waiting to go back to court for her case to be heard.

The inquest is scrutinising the care she received in HMP Holloway before she died and whether there were any shortcomings in it. The jury is looking at a range of factors including whether her death could have been avoided, the state of her mental health, whether her treatment was appropriate, whether she was at risk of suicide and self-harm and whether she should have been in prison or in a mental health unit.

She died on 11 January 2016 in Holloway’s C1 unit and was found that morning with strips of bed sheets tied around her neck as a ligature. She was subject to hourly observations and could only be unlocked from her cell if four prison officers were present. The prison closed last July.

The jury heard that Reed had previously been in segregation and monitored with two observations per hour. She was then moved to the C1 assessment unit with observations reduced to one per hour.

Sean Horstead, the family’s barrister, described her poor mental state just before she died – she was screaming, shouting and chanting.

A prison officer, Ansar Din, said he knew Reed was at risk of self-harm and revealed that she was top of a list of inmates waiting to be transferred from prison to a mental health unit.

“I believe she was the first one to be prioritised for hospital. I didn’t know the timescale; she could have been in C1 for weeks.”

A second prison officer, Dawn Bailey, said that Reed’s behaviour had been “very challenging” over the weekend, just before she took her life.

“She was either shouting or banging or standing by the sink and I couldn’t get anything out of her, she was completely zoned out. Even if I spoke to her I couldn’t get anything from her,” she said.

Bailey said that she had failed to make full notes in the ACCT records – a series of forms held together in a bright orange folder opened in response to concerns about a prisoner who is at risk of self-harm or suicide.

She had omitted to note in the file that Reed had requested that her belongings be taken away shortly before she took her life. Reed had told Bailey she wanted to speak to the Independent Monitoring Board. Bailey told the court she could not remember how she took that request forward.

“I suggest that request of hers fell on deaf ears,” said Horstead.

When a third officer, Danny Newland, saw Reed lying on the bed he was not sure if she was dead or not.

“Because she had been so aggressive at that time I wasn’t wholly convinced that she wasn’t going to jump up and have a go at staff,” he said. He added that Reed’s death was “very upsetting”.

In a statement read out by the coroner at the opening of the inquest, Reed’s mother Marylin Reed paid tribute to the daughter she lost. “Sarah was adored and loved by the whole of her family. She was very much treasured. Her death has been devastating for us. Before she was remanded she had started to turn her life around. We are hoping to get to the bottom of what caused her death.”

She added that Reed had been traumatised by the loss of her baby and that this was compounded when she and the baby’s father had to carry their dead child from the hospital to the undertaker. After that she developed grief depression, schizophrenia and bulimia. She was remanded while the court obtained a “fitness to plead” report. Before she was remanded she had started to turn her life around. “One thing I’m sure about is that she died unexpectedly,” said Marylin Reed.

The inquest continues.