Inquest into death of Alex Davies in HMP Styal concludes neglect contributed to her death
14 November 2025
Garden Court North’s Ciara Bartlam represented the mother of Alex Davies during the inquest into her daughter’s death. Credit: Richard Coomber / Shutterstock.
The death of a vulnerable young woman who took her own life in prison on Christmas Eve last year was contributed to by neglect, an inquest jury has found.
Alex Davies, 25, from Liverpool, who suffered severe borderline personality disorder and post-traumatic stress disorder, was found dead in her cell on the Care and Separation Unit at Styal Prison, the inquest at Cheshire Coroner’s Court heard.
At the 11-day inquest which concluded on 3 November, the jury found that neglect contributed to her death – a rare conclusion only reached where there has been a gross failure to provide basic medical attention, causing an individual’s death.
Garden Court North’s Ciara Bartlam represented Alex’s mother Stacie at the inquest, instructed by Broudie Jackson Canter’s Nicola Miller.
A timeline of events
The jury heard how psychiatrists said Alex should have been placed in a mental health hospital rather than prison. She was kept on the Care and Separation Unit (CSU), which is like a segregation unit, for 27 days from 9 November to 6 December 2024.
For 14 of those days, Alex was placed on constant observation because the risk to her life had substantially increased. National guidelines state that prisoners who are at risk of self-harm and suicide should only be kept in CSU in exceptional circumstances, as it is well documented that a person’s mental health will likely decline while they are there. Numerous witnesses to the inquest said that Alex was kept on the CSU because her risk to self could not be safely managed elsewhere in the prison.
Additionally, Alex had been discharged from the Integrated Mental Health Team’s (IMHT) caseload following an assault on staff. It became apparent that concerns were being raised about some of the IMHT nurses’ interactions with Alex. It was reported that one of the nurses had told Alex that she would not be getting medication for depression and epilepsy “until she behaves” and prison staff reported uncaring and unprofessional attitudes by IMHT staff towards Alex.
On Christmas Eve 2024, Alex was on her way back to her cell following a treasure hunt when a prison officer told her to “stop perving” when she tried to speak to another prisoner. Alex became upset, ran off and was forcibly restrained before being taken to the CSU. In distressing footage shown of the restraint and relocation to the CSU, Alex is repeatedly telling officers “she called me a perv”. Alex also screamed “I don’t want to go to this hell cell” and begged staff not to take her there over Christmas. The Prison and Probation Ombudsman found that force was not necessary and attempts were not made to de-escalate the situation by talking with her.
A male nurse, who walked away after Alex put a mattress against the observation window when he asked her if she would like to talk, admitted at the inquest that he incorrectly filled out a healthcare algorithm which should have raised a red flag about Alex being kept in CSU. Within about five minutes of the door to Alex’s cell being closed, she attempted to self-harm and officers had to force their way into her cell because she had blocked the door. Items of clothing and bedding were removed from Alex’s cell, while the Governor in charge of the decision to segregate stood outside.
After repeated attempts at self-harm Alex was left wearing nothing but a pair of boxer shorts while under observation by male prison officers. Despite the persistent attempts at self-harm she was not put on constant watch. There were five occasions in which officers entered her cell in order to remove ligature material from her cell but these incidents were not escalated to Senior Officers or the Duty Governor.
Although an IMHT nurse told the inquest that she had approached Alex’s cell on the CSU and asked if she wanted to be reviewed by the mental health team, there was no evidence of any interaction between Alex and the IMHT on any of the CCTV or body worn footage that captured Alex’s movements on the CSU on 24 December 2024. During the inquest proceedings, it was disclosed that prison staff reported unprofessional attitudes towards Alex by members of the mental health team that occurred on the day of her death, including one IMHT member using a derogatory phrase to describe Alex while visiting the unit that morning.
The jury’s findings
Alex, who had been in and out of mental health hospitals since the age of 14, saw her mental health deteriorate after she was taken off the antipsychotic drug, Clozapine, and was arrested in October last year after threatening her psychiatrist and possession of a knife.
The jury found that the “stop perving” comment probably contributed to the decline in Alex’s mental state, among other factors, and that the completion of the healthcare algorithm was inappropriate.
The fact that Alex was taken to the CSU on 24 December probably contributed to her death and was a failing of care. The decision not to place Alex on constant observations when she first self-harmed on the CSU, only 5-minutes after she was last seen by staff at a time when governors were present and able to make this decision, was also a failing in care and probably contributed to her death.
Overall, the jury concluded that there was a gross failure to place Alex on constant observations whilst on the CSU and as such her death was contributed to by neglect.
Alex’s mother Stacie said: “Alex was my little girl and my best friend. All she wanted was help but her situation in prison made her feel like she had no other option but to take her own life. I would like to see Styal Prison condemned as I wouldn’t wish what happened to my daughter on my worst enemy.”
“Alex suffered from age regression so for her the thought of being on her own in that cell at Christmas would have been torture. Instead of caring for her the nurse just walked away and didn’t raise the fact that she might be at risk. My girl wanted help when she was arrested and I know she wouldn’t have wanted to kill herself. The neglectful actions of the prison staff contributed towards her death.”
Alex’s father Allan said: “This conclusion is bittersweet justice. Dying through neglect in a prison in the 21st century is truly appalling, and I hope that changes are made to prevent this from happening to somebody else. Alex was such a joyful child and we will always miss her.”
Nicola Miller said: “For a young vulnerable woman to be neglected in this way in a state prison that allowed her to take her own life is truly abominable. Alex should never have been sent to the wholly inappropriate surroundings of a prison where she was wrongly placed in effective solitary confinement as they didn’t know what else to do with her or know how to deal with her needs.
Moreover, the treatment of Alex by some staff was cruel. She was desperate for help, but instead was neglected. HMP Styal is a women’s prison with a high number of self-inflicted deaths, compared to the rest of the female estate. Significant changes need to be made to ensure the women are getting the help and support they need, and lessons need to be learnt to prevent more young lives being lost.”
Ciara Bartlam represented Alex Davies’ mother Stacie during the inquest, instructed by Nicola Miller from Broudie Jackson Canter.
If you are affected by the issues in this release, Samaritans are available 24/7. Call 116 123, email jo@samaritans.org, or visit www.samaritans.org.
Additional media
Broudie Jackson Canter – Inquest into death of Alex Davies in HMP Styal concludes neglect contributed to her death
For further information, please contact Alex Blair, Communications Manager at Garden Court North Chambers: ablair@gcnchambers.co.uk
