Show caption Sarah Reed’s mother Marilyn says she will fight to ensure other women do not suffer her daughter’s fate. Photograph: Graeme Robertson/The Guardian UK news ‘I sleep at peace at night because I know I fought for my daughter to the very last’ As the inquest into the tragic death of Sarah Reed ends, her mother Marilyn explains why this fragile young woman should never have been in jail Yvonne Roberts Sat 29 Jul 2017 19.04 EDT Share on Facebook

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On 11 January 2016 Sarah Lynne Reed, 32, was found dead in her cell in London’s Holloway prison. A jury was told at her inquest – which opened earlier this month – that she died by “self strangulation”, the tragic conclusion of more than a decade of sporadic bouts of mental ill health.

Sarah’s final days were harrowing. She was hallucinating, chanting, without the medication she had relied on for years, sleepless, complaining a demon punched her awake at night. She was on a basic regime, punishment for what was classed as bad behaviour. In spite of her mental and physical fragility, she was isolated, the cell hatch closed, without hot water, heating or a properly cleaned cell. “For safety and security” a four-strong “lockdown” team of prison officers delivered basic care.

As the inquest unfolded and the details of her suffering were revealed, Sir Peter Thornton QC, HM assistant coroner, asked the jury a potentially groundbreaking question: should Sarah have been in prison at all?

Marilyn Reed, 52, Sarah’s mother, is in no doubt that she should not. The coroner’s recommendations will be delivered this week. The Reed family and friends – a redoubtable group that includes grandmother and aunt, along with members of the Justice for Sarah Reed campaign – intend to lobby to establish a monitor of coroner’s recommendations and to fight to have them made mandatory. “Sadly, Sarah’s story is not uncommon,” says Lee Jasper of the campaign. “It’s about race, class, gender and the lack of resources for mental health.”

Marilyn Reed cares for her surviving daughter, aged 30, who has Down’s syndrome and her granddaughter, Sarah’s child, aged 16. Marilyn is fiercely eloquent in her description of one family’s fight for justice and proper care. “We are upright, sober, a family of ministers,” she says. “I was reared to stand tall in a storm.”

Her recollections of Sarah are far from the pen portrait drawn in court of an occasionally violent, spitting, tormented drug addict, weakened by bulimia. Sarah’s anti-psychotic medicine had been reduced in November and all medication, including sleeping tablets, were completely halted in December. For several days before her death, she had been forbidden showers. “She was my water baby. She loved to have baths,” says Marilyn. “That’s so cruel. Growing up, she was bright, warm, honest. I reared her to be confident and caring.”

In her teens Sarah met and began a relationship with a builder. They moved in together and had a daughter, Tianna. “She was gorgeous, but Sarah knew something was wrong,” says Marilyn. “Tianna had a rattle in her throat when she breathed. Four times she stopped breathing and was taken by Sarah by ambulance to A&E. On every occasion, Sarah was told the child had a cold.”

Sarah’s instincts were correct. Tianna was eventually diagnosed with muscular atrophy and died in 2003, aged nine months. Inexplicably, the couple were given her body wrapped in a quilt and directed to take a taxi to a funeral director. Sarah witnessed the initial decomposition as she held Tianna in her arms. “After that, she was haunted by a vision of the bodily fluids. Sarah always carried a photograph of Tianna, taken after her death,” her mother says.

A little later, Sarah met a man who would be her partner for several years. “Sarah said he looked like her baby. He extracted everything he could from her. Even after she died, when we went to her flat, he was there. ‘Are you keeping memorabilia?’ I asked him. ‘No,’ he said. ‘I’m selling it.’”

In 2012, Metropolitan police constable James Kiddie arrested Sarah for shoplifting – she was subsequently acquitted. On CCTV, Kiddie was seen pulling Sarah to the floor by her hair, dragging her across broken glass, punching her in the head and body, breaking two ribs. The cameras had delivered rough justice for Sarah but, released without her consent, she also saw it as “a public humiliation”, as thousands viewed the footage on YouTube. Kiddie was convicted of common assault, dismissed from his job and given 150 hours’ community service. Sarah, in contrast, while committed to a psychiatric hospital, was charged in October 2014 with GBH with intent. Sarah said she had fought off an older male patient who had tried to sexually assault her.

At the inquest, the jury was told that Sarah had been remanded to Holloway, now closed, for psychiatric reports to establish whether she was fit to plead. Three months later, she was still in Holloway, lost in the system, mentally disintegrating, the report still not written, nor a letter sent to arrange her transfer to a secure psychiatric hospital.

The inquest jury decided delay and failures in treatment significantly contributed to Sarah’s death. Sarah had complained of bullying. “We do not believe that it was physically possible for Sarah to tear up thick prison sheets, tie knots and take her own life in a 10-minute window,” Marilyn says. “There are questions still to be answered.”

Prior to Holloway, after several periods in psychiatric hospitals, stability had entered Sarah’s life. She had a studio flat, a hard-working new partner and support from a community psychiatric team. A photo of Sarah used in the campaign is from that period. She is smiling with luminous eyes. “She’d showered, dressed, she was going out for dinner with her partner. She was becoming normal,” says Marilyn.

The inability of mental health services to cope means thousands of vulnerable women like Sarah are on a conveyor belt to understaffed prisons where, frequently, harsh discipline is imposed. Sarah had allegedly tried to cut her throat two months before arriving in Holloway, yet she was judged low risk and observed only once an hour. “Sarah couldn’t handle prison and prison couldn’t handle her,” the inquest jury heard from a fellow prisoner.

“I sleep at peace at night because I know I fought for Sarah to the very last,” Marilyn says. “I’ve got a granddaughter who sat her GCSEs during her mother’s inquest. Her ambition is to be a midwife, so I’m not giving up yet.