In November 2021, Diana Ocean Grant, a woman living with paranoid schizophrenia — died alone in her prison cell at HMP Bronzefield. Her death was not inevitable. It was the result of cascading failures across healthcare, policing, and prison services. The coroner’s Regulation 28
Report to Prevent Future Deaths lays bare the systemic neglect that contributed to her final hours.
Diana had lived with schizophrenia since 2002, usually managed with anti-psychotic medication.
But in late 2021, signs of relapse were clear: withdrawing from her mother, drinking more, erratic behavior in public. On 12 November, her mother raised the alarm with the Community
Mental Health Team (CMHT). The response? A note to review her at a meeting days later. No
urgent referral. No immediate assessment.
By 17 November, Diana’s condition had worsened. Taken to the CMHT by her mother, she was
judged to need hospital care. Yet arrangements stalled. She left suddenly, attacked her mother,
and was arrested.
At St. Mary’s Hospital, psychiatric liaison staff agreed she needed a Mental Health Act
assessment. But no doctor assessed her. Protocols were unclear, responsibilities blurred, and
opportunities missed.
Police then transferred Diana to Colindale custody. Again, no assessment was secured. She was
charged with attempted murder and remanded to prison.
At Bronzefield, Sodexo Limited and CNWL NHS Foundation Trust staff received urgent warnings.
A suicide/self-harm alert form was handed over. Emails requested her placement in the
healthcare unit and opening of an ACCT process. Yet these safeguards were ignored.
Instead, Diana was placed in an ordinary cell. On her first night, she screamed and ran around,
clearly in psychosis. She was not seen by a doctor. No ACCT was opened. By the next evening,
she was dead, suffocated after placing a foreign object in her mouth.
Senior Coroner Richard Travers concluded Diana’s death was “probably contributed to more
than minimally” by failures at every stage. Sodexo Limited and CNWL NHS Foundation Trust
staff were singled out for failing to act on urgent warnings.
The report also highlights a broader systemic issue: the lack of secure mental health unit
capacity. Even today, people judged dangerous yet in need of urgent psychiatric care are often
detained in prison for months before hospital transfer. The average wait? 80–90 days.

Diana’s case is emblematic of a wider crisis. Prisons are not hospitals. They cannot provide the
therapeutic environment, compulsory treatment, or specialist care that psychiatric units offer.
Yet they continue to be used as holding spaces for people in acute mental health crisis.
The coroner’s concern is stark: unless action is taken, future deaths will occur.
This tragedy demands accountability. Sodexo Limited must answer for its operational failures.
NHS services must ensure communication between clinics, hospitals, and CMHTs. Police and
courts must prioritize diversion to healthcare over custody.
But beyond accountability lies reform. Secure mental health unit capacity must be expanded.
Protocols must be clarified. Staff must be trained to recognize and act on psychosis.
Diana Ocean Grant was more than a case file. She was a daughter, a woman living with a
condition that required care, not punishment. Her death is a reminder of the human cost of
systemic neglect.
Her story should galvanize change. Because no one should die in custody for want of a bed, an
assessment, or a protocol followed.