How a talented teenage girl was failed by jail ill-equipped to cope with vulnerable prisoners

At the age of 15 life seemed to hold everything for Sarah Campbell. She had ambitions to pursue a fine art degree after her A-levels and her talent at tennis had put her on the fringes of her county's tennis squad. She also did karate (earning a purple belt) and attended drama classes.

At the age of 15 life seemed to hold everything for Sarah Campbell. She had ambitions to pursue a fine art degree after her A-levels and her talent at tennis had put her on the fringes of her county's tennis squad. She also did karate (earning a purple belt) and attended drama classes.

But within three years she was dead after becoming addicted to heroin, stealing to feed her habit and being put in a prison that was chronically ill-equipped to deal with vulnerable young women such as her.

Those serious shortcomings at Styal prison, Cheshire, where she took a fatal overdose of antidepressants, were exposed yesterday at the end of a two-week inquest. It learnt that, despite seven previous attempts to hang herself there, staff acted against a doctor's warnings by sending her to a segregation unit, shut the door on her after she had overdosed, and could not agree who should call an ambulance to take her to hospital.

The inquest jury found that the prison had failed in its duty of care to Campbell, one of six vulnerable women prisoners to die in a 12-month period at Styal. In a narrative verdict, it detailed a catalogue of failures that led to her suicide at an establishment where "more emphasis was put on auditing, than prisoners' welfare".

The jury heard how Campbell's attempts to hang herself were among her 27 separate instances of self-harm at Styal between May and November 2002. But prison officers neither understood nor used the self-harm form (20/52 SH) on which each such incident should be logged. Campbell died on 18 January 2003, three days before her 19th birthday and one day into a three-year sentence for manslaughter.

For all her youthful achievements the teenager, from Malpas, Cheshire, suffered from low self-esteem, and at 15 her doctor prescribed antidepressants. She dropped out of her art course within a term, began to smoke cannabis and moved to London, where she was introduced to heroin. A psychiatrist who saw Campbell 40 times in two years after she moved back to Cheshire, told the inquest she was "one of the most unhappy people I have ever met".

Campbell was in Chester city centre, desperate for a fix, when she and a friend hassled Amrit Bhandari, 72, bundling him into a doorway and stealing his credit cards and wallet in May 2002. He collapsed from a heart attack and died. Campbell then received the first manslaughter conviction based on an harassment charge.

Campbell's mother, Pauline, a retired lecturer and civil servant, became increasingly concerned about her daughter's mental health while visiting her on remand at Styal in 2002, the same year that the weaknesses in Styal's system for dealing with vulnerable women were highlighted in a Prisons Inspectorate report.

After the teenager's conviction, a doctor and nurse both recommended Campbell be remanded to a "safe cell", under surveillance, as a suicide risk. But the deputy governor, Jean Craven, overruled the decision. Asked if the segregation unit was a "dumping ground for vulnerable people", Mrs Craven told the inquest: "I cannot disagree with you but we have to work with what we've got at the time."

Prison officers admitted they had neither consulted nor added to Sarah's 20/52 forms before her death, despite her attempted hangings. "She was just behaving like the same old Sarah," one told the jury. After she had taken her fatal dose of 120 antidepressants, the door was closed on Campbell's segregation cell as prison staff went in search of medical equipment. By the time they returned she was seriously ill and had vomited. Confusion then ensued over who should call an ambulance - a nurse asked a prison warder to do so, only to be told later that it was a nurse's job. A leading toxicologist told the jury that, but for the 10-minute delay, Campbell might have lived.

The Cheshire coroner, Nicholas Rheinberg, called on the Prison Service to review its segregation units nationwide and introduce training for prison officers in suicide and self-harm risks.

The campaign group Inquest renewed its appeal last night for a public inquiry into the number of suicides among women inmates: 13 last year and a record 14 in 2003. Deborah Coles, its director, said: "The wider issue is the over-use of prison for women and the specific mental health needs of these women, which are being ignored."