A transgender woman who died while on remand in a men’s prison was held in the correct jail but let down by the NHS, Prison Service and her family, an inquest has heard.
Vikki Thompson, 21, was found dead in her cell at HMP Leeds with a ligature around her neck.
But the foreman said “more attention should have been paid” to her.
“Vikki has been let down by various departments including the NHS, Leeds Community Healthcare NHS Trust, the Prison Service and also by her family,” he said.
“Although these departments were individually aware of Vikki’s history, the overall coordination of her mental and health state were lacking in any form of organisational structure.
During her last stay at HMP Leeds, the management of her treatment and mental state of mind were also lacking in professionalism and inadequate for an individual of such complex issues.”
But he said: “All evidence points to services under immense pressure, understaffed and working in extremely difficult day-to-day situations.”
The foreman said the jury had concluded that the prison was “the right one for Vikki”.
Vikki, from Keighley, West Yorkshire, had identified as female since she was 10 years old but never had any surgical or hormone treatment.
The inquest heard she did not have a Gender Recognition Certificate establishing her female identity so she was sent to a male prison.