A mentally ill prisoner was found hanged in his cell hours after telling staff he heard voices “telling him to kill himself”, a report has found.
Michael Berry was deemed to be “high risk” when he was remanded at HMP Bedford in March 2017, appearing in a “fragile” state and detoxifying from heroin and crack cocaine use.
The report by the Prisons and Probation Ombudsman found Mr Berry told staff he was “finding it hard to ignore the voices telling him to kill himself, was distressed, hopeless, teary and prone to acting impulsively”, prompting staff to increase self-harm monitoring observations from twice an hour to five times an hour.
Staff and prisoners said they heard Mr Berry, 24, calling from his cell, although a doctor said the prisoner would not engage with him. He was also described as “arguing with himself and seemed tormented”.
A subsequent check by staff noted Mr Berry was “pacing up and down in his cell and talking to himself”. Around 20 minutes later, he was found hanged.
The watchdog found failings previously identified in the mental health support offered to inmates at the jail had not been properly heeded.
It said Mr Berry was at Bedford jail having been charged with 22 offences including violence, kidnap and sexual assault of an adult male.
He had a significant history of drug and alcohol abuse and had recently been admitted to a mental hospital twice, including following an attempt to jump out of a window.
The report said it was “concerning” there was no record of an email from the court to theprison explaining Mr Berry’s fragile mental state and the risk of self-harm.
Mr Berry was the eighth prisoner to take his own life at Bedford since 2013.
In six of the investigations, the ombudsman found staff operated suicide and self-harm prevention procedures ineffectively and recommendations were made to improve the assessment, care in custody and teamwork (ACCT) process.
Four of the investigations identified failings in the mental health support offered to prisoners and, as Mr Berry’s case shows, this continued to be an issue.
There has been a further self-inflicted death at Bedford since Mr Berry, the watchdog said.
The provision of work, training and education had improved at HMP Woodhill and its rehabilitation services were good, but violence and a high number of self-inflicted deaths were significant concerns, said Martin Lomas, Deputy Chief Inspector of Prisons. Today he published the report of an unannounced inspection of the jail near Milton Keynes.
HMP Woodhill is as a core local prison, meaning while the bulk of its population is a mixture of remanded and short-sentenced men with the mental health, substance misuse and other issues typical of local prisons, it also has a high security function for a small number of category A prisoners. The prison also has a Close Supervision Centre (CSC), part of a national system for managing some of the most high-risk prisoners in the system, which is inspected separately. Previous inspections of HMP Woodhill have repeatedly raised concerns about the prison and, in particular, weaknesses in the support of men at risk of suicide or self-harm and the poor provision of work, training and education. This inspection found real improvements had been made but more still needed to be done to reduce the likelihood of further self-inflicted deaths. There had been five more self-inflicted deaths since the last inspection, making nine since 2012. This was an unacceptable toll.
Inspectors were concerned to find that:
early days in custody are a critical time and five of the nine deaths since 2012 had involved new arrivals who had been in the prison for less than two weeks;
reception processes were efficient but the role of the first night centre was undermined because it was also used to hold prisoners difficult to locate elsewhere;
some prisoners requiring opiate substitution treatment or alcohol detoxification were mistakenly placed in the first night centre rather than the specialist stabilisation unit, which was particularly dangerous for prisoners requiring alcohol detoxification;
too many first night cells were dirty and poorly equipped;
recommendations by the Prisons and Probation Ombudsman following previous deaths in custody had not been implemented with sufficient rigour;
there were not enough Listeners (prisoners trained by the Samaritans to provide confidential emotional support to prisoners);
mental health services had been hit by staff shortages and only 18% of residential staff had received mental health awareness training in the past three years; and
although the prison felt calm, a sizeable minority (one in five prisoners) said they felt unsafe at the time of the inspection and levels of violence were higher than elsewhere and included some serious assaults on prisoners and staff.
However, inspectors were pleased to find that:
impressive progress had been made in the provision of work, training and education, and the provision of activity for short-term prisoners was an example other local prisons could follow;
the quality of teaching and learning had improved and there was good emphasis on helping prisoners to improve their literacy and numeracy;
activities were intelligently geared to the labour markets in areas to which most prisoners would be returning;
the support given to prisoners at risk of suicide and self-harm was often better than the records showed and those prisoners subject to ACCT monitoring told inspectors they felt well cared for;
security arrangements were generally appropriate for the population;
drug availability was lower than elsewhere, although the prison needed to be alert to the increasing availability of Spice;
the environment in the segregation unit had improved and staff worked well with some very complex prisoners;
there had been good progress in reducing the backlogs in risk assessments and sentence planning and public protection arrangements were good; and
despite the complexity of new arrangements, including two new community rehabilitation companies working in the prison, most practical resettlement services were good.
Martin Lomas said:
“HMP Woodhill is an improving prison and its very good purposeful activity and good rehabilitation services are better than we have seen recently in many other local prisons. Good outcomes in these areas help to create a sense of purpose and hope and reduce frustration and tension. Despite this, levels of violence are a significant concern and the number of self-inflicted deaths in recent years has been unacceptably high. The main priority of the prison must be to tackle these two areas.”
Michael Spurr, Chief Executive of the National Offender Management Service, said:
“As the Chief Inspector says, Woodhill has made impressive progress in providing work, education, training and support to help prisoners turn their lives around.
“Given the significant operational pressures the prison has faced this is an excellent achievement.
“Tackling increased levels of violence and preventing suicides is the top priority for the Governor and for the Prison Service as a whole. Tragically, as recent incidents at Woodhill have demonstrated, the challenge is considerable – but we will use the recommendations in this report to further develop and improve our approach.”
Sheldon Woodford was found hanging in his cell in HMP Winchester on 9 March 2015 and was pronounced dead at hospital on 12 March 2015.
After a two-week inquest, the jury has returned a highly critical narrative conclusion finding that lack of staff, training and consistent care across the prison and healthcare led to a failure to spot obvious and escalating patterns of risk regarding Sheldon’s self-harm.
Despite the self-harm warnings accompanying Sheldon’s arrival at the prison, neither the reception officer nor the first nurse who assessed Sheldon, placed him under suicide and self harm management programme in part due to the fact that vital information was not properly shared or made available. His risk of self harm and suicide was not formally assessed until ten days later, after Sheldon had cut his wrists.
The level of observations Sheldon was monitored under did not always always reflect his risk of self-harm – including staff only being required to check Sheldon twice an hour when he returned to prison after a serious suicide attempt. Meetings in relation to his risk of self harm were often not multidisciplinary and the prison staff did not receive adequate training to identify and manage his risk of self harm.
At Sheldon’s final case review, held three days after he returned from intensive care having attempted to hang himself (and five days before he placed a ligature round his neck for the second, fatal time), Sheldon’s risk was graded as “low”. This was despite the fact that the hospital who had discharged Sheldon had described him as “high risk”, a prison GP considered his risk to stem from his “impulsive” and “unpredictable” behavior, and the prison psychiatrist, told the inquest that the “low” grading was incorrect and inappropriate.
The jury retuning a highly critical narrative conclusion, found that the failure to identify Sheldon’s escalating levels of risk of self harm, insufficient levels of prison and healthcare staffing, inadequate training on how to assess and manage risks of self harm contributed to Sheldon’s death. They also identified unstructured application of the suicide and self harm management programme resulting inadequate integration between prison and healthcare as a contributory factor in his death.
The Coroner indicated that she will be making recommendations to prevent future deaths in relation to training of prison staff and officers in suicide and self harm management and also in relation to the sharing of information.
Sheldon Woodford’s partner Alex said:
“We always believed that Sheldon was badly let down by the system at HMP Winchester and we are pleased that the jury found that this was the case.To have had to visit him once in an induced coma after a hanging attempt was bad enough, but we had hoped that the prison would learn from the risks that Sheldon was clearly presenting and provide him with the care and support he needed.To have to return again to an intensive care unit less than two weeks later, and to have to make the horrendous decision to turn off his life support machine, was devastating and broke our hearts.
We hope that the jury’s highly critical findings and the coroner’s Prevention of Future Deaths Report will mean that eventually other families will not have to go through this. We also hope that the government will consider the failures in staffing levels and training which contributed to Sheldon’s death before making any further cuts to the prison system”
Alex Tasker’s solicitor Karen Rogers said:
“The failure to properly implement ACCT procedures in this case was shocking. The evidence showed there was far too much reliance on prisoners’ self-report, and insufficient attention paid to obvious and escalating risks of self-harm.”
Deborah Coles : Director of INQUEST said :
“Sheldon’s risk of suicide should have been obvious to anyone who was responsible to keep him safe. That the jury found such fundamental failings in care, training and staffing levels sends a clear warning to Government about the crisis in prisons. There have been 3 further self inflicted deaths in HMP Winchester. The Prisons Minister must account to Sheldon’s family as to what action is to be taken in response to the serious failings identified.”
A man died in police custody on the day that figures were released showing the highest number of deaths in detention for five years, Northumbria Police confirmed.
A man became ill while in custody at Forth Banks station in Newcastle on the same day he was arrested, police said. He was pronounced dead at 3.45pm on Thursday.
Assistant Chief Constable Jo Farrell said: “This death within our custody is a tragic incident.
“We immediately referred the death to the IPCC (Independent Police Complaints Commission) for independent investigation, as we would with any death in police custody, and we are assisting them fully.”
She added: “Northumbria Police takes its commitment to the welfare of prisoners extremely seriously. This death comes on the same day the IPCC released their annual statistics on deaths during or following police contact.
“Northumbria Police’s statistics were included in this report and as a force we welcome this in the interests of openness and transparency.”
Figures from the IPCC showed that there were 17 fatalities during or after detention in England and Wales in 2014/15 – six more than the previous year and the highest annual total since 2010/11.
There were also 69 apparent suicides after release – 50% higher than in 2010/11.
Home Secretary Theresa May has launched a review into deaths in police custody, saying they have the potential to “dramatically” undermine relationships between the public and police.
The 17 deaths recorded in or after police custody in the last financial year is “broadly in line with the average” over the last six years, the IPCC said. Last year’s total of 11 was the lowest since recording began in 2004/5.
Six officers in the police custody death of Freddie Gray are facing multiple charges including murder and manslaughter, Maryland’s state attorney has announced.
One officer faces a second-degree murder charge while the other officers face manslaughter or assault charges, among others, according to Marilyn Mosby.
She said the officers failed to get Mr Gray medical help even though he requested it repeatedly after he was arrested on April 12. She called his arrest illegal.
At some point while he was in custody, he suffered a mysterious spinal injury and died a week later.
Meanwhile, the Baltimore police officers union is asking Ms Mosby to appoint a special independent prosecutor for the investigation.
Fraternal Order of Police local president Gene Ryan told Ms Mosby in a letter that the union is concerned about her ties to the Gray family lawyer Billy Murphy.
Mr Murphy was among Ms Mosby’s biggest campaign contributors last year, donating the maximum individual amount allowed, 4,000 US dollars, in June. He was also on her transition team after the election.
The union says none of the six officers suspended in the investigation is responsible for Gray’s death.
The deaths in custody of hundreds of people with mental health problems could have been avoided, according to an inquiry.
Repeated basic errors, poor communication and a lack of rigorous procedures were found to have contributed to deaths in police cells, prisons and psychiatric hospitals.
The Equality and Human Rights Commission (EHRC) examined the period from 2010-13, during which it said 367 adults with mental health conditions died of non-natural causes in psychiatric wards and police cells, while 295 adults died in prison, many of whom had mental health conditions.
The EHRC has recommended a framework aimed at policy makers and front-line staff to help protect people in custody.
Professor Swaran Singh, lead commissioner on the inquiry, said: “Human rights are for all of us and nothing is more fundamental than our right to life.
“When the state detains people for their own good or the safety of others it has a very high level of responsibility to ensure their life is protected.
“For people with mental health conditions that is a particular challenge with a large number of tragic cases over the past few years where that responsibility has not been met.
“The commission, as Great Britain’s national human rights institution, carried out this inquiry in consultation with other expert bodies to examine what lessons can be learned and how to prevent further unnecessary and avoidable harm and heartbreak.”
The report found basic mistakes were repeated, such as failing to properly monitor patients and prisoners at serious risk of suicide, and not removing ligature points in psychiatric hospitals despite their common use in suicide attempts.
Misplaced concerns about data protection were blamed for prison healthcare staff not telling officers on the wing that an inmate had suicidal tendencies. A failure to update patients’ risk assessments was also criticised.
A central record is kept of the deaths of people with mental health issues in prisons and police stations, but not in hospitals. The EHRC noted that there is no independent body charged with ensuring that effective investigations take place in the latter, and claimed some staff feel they cannot speak out openly.
The commission made a number of recommendations such as setting up trigger systems to alert staff to events or dates which could prompt self-harm, such as the anniversary of a bereavement, and embedding a mental health liaison officer in each police force.
Inspector Michael Brown, co-ordinator for mental health at the College of Policing, said: “There is a growing demand on front-line police officers and staff in helping those of us suffering mental health difficulties.
“While the police service should not be filling gaps in mental health services we need to ensure that we give front-line officers and staff basic training in identifying signs and symptoms.
“Officers and staff also need to be equipped with the knowledge of where to divert vulnerable people into a healthcare setting so that they can receive expert care. That means not using police cells as a place of safety for those detained in distress.”
The mother of a jailed 17-year-old boy who hanged himself after being bullied has said she wakes up to a nightmare every day and claimed prison staff in Wigan could have prevented his suicide.
Staff at Hindley youth offenders institution have been accused of failing to give Jake Hardy proper support before he fatally injured himself in his cell on January 20 2012. He was taken to hospital but died four days later.
The teenager, who was serving six months for affray and common assault, had previously complained that he was being picked on and had said that he was better off dead, charity INQUEST said.
An inquest jury at Bolton Coroner’s Court found that he had died as a result of his own deliberate act but that there was not enough evidence to prove he intended to commit suicide, and they highlighted a number of failures at the youth jail.
His mother Elizabeth Hardy said: “While we finally have some answers, as a family we have been shocked by the attitude of some of the officers, who clearly just didn’t care that my son was being bullied.
“Other officers took such small steps and but never followed it through to the end. If they had done their job properly they could have prevented Jake’s death.
“I feel distraught that Jake could have been moved to a safer cell the night he hung himself. Every day we have to wake up to this nightmare that Jake died and some officers could have helped him.
“Jake was too vulnerable and should never have gone to a place like Hindley to start with. I kept my son safe for 17 years yet Hindley couldn’t keep him safe for two months.”
Jake had special needs and had previously been bullied at school before he was sent to the jail in December 2011.
In his first week there, he said that other boys on his wing were trying to intimidate him, INQUEST said, and a short while later said he would be better off dead and that officers “took the piss out of him”.
On January 17 2012 he cut his wrist and told staff he had been suffering verbal abuse for “a prolonged period of time”, and the following day his mother warned a senior officer that he had thought of ending his life.
Over the next few days inmates shouted through his cell door and kicked it, and he damaged furniture in his cell over the abuse.
On January 20, a senior officer locked him in his cell, saying he was going home, and less than an hour later the teenager was found hanged.
He left a note saying: “So mum if you are reading this I not alive cos I can not cope in prison people giveing me shit even staff”, and had written on a complaint form that he wanted staff to “do their job properly”.
The jury found that Jake’s death was contributed to by failures to give him enough support, record his suicidal thoughts and reports of verbal abuse, and move him to another cell.
On the day he died, there were also failures to let him use the phone, protect him from other inmates, and review his risk of self-harm and the number of times he would be checked.
The family’s solicitor Helen Stone said: “The jury have delivered a devastatingly critical verdict identifying a range of serious failings from the moment Jake entered Hindley until the time he hanged himself.
“He constantly asked staff to protect him from bullying, they failed to do so and this caused to him take his own life.
“As Jake said in the complaints form he wrote, all Jake wanted was for staff to do their job properly, they failed to do so, they failed him, and materially contributed to this child’s death.”
Deborah Coles, co-director of INQUEST, said: “Jake Hardy was utterly failed by prison officers and a prison system supposed to protect him.
“Every warning sign about his vulnerability was starkly evident but systematically ignored.
“The decision to ignore the heartbreaking pleas for help from a scared child alone in his cell, resulting in his desperate act, should shame us all.
A Prison Service spokeswoman said: “Our sympathies are with Jake Hardy’s family and friends.
“We will consider the findings of his inquest to see what lessons can be learned in addition to the Prisons and Probation Ombudsman’s investigation.
“Since Jake’s death we have made strenuous efforts to make changes and share learning. This includes the circulation of a number of bulletins that highlight key learning points and suggested actions to establishments
Prisons and Probation Ombudsman Nigel Newcomen, who investigated Jake’s death, expressed concerns about the treatment of children behind bars.
He said: “This is a disturbing story of failure to protect properly a young person with multiple vulnerabilities. None of the systems designed to protect children at Hindley worked effectively and there were many failures to share information.
“He was very vulnerable but it appeared almost as if no-one heard what he was telling them or appreciated that his sometimes challenging behaviour might be a symptom of significant distress.
“Tragically, this is one of three apparently self-inflicted deaths of children in custody my office has investigated in the past two years. In each case, I have been concerned that too many of the systems in YOIs holding children replicate those in adult prisons. Once again, a number of our criticisms in this investigation repeat this theme.
“Accordingly, while a large number of recommendations are made to learn lessons and address the specific failures identified in his case, there are also some broader recommendations to the National Offender Management Service and Youth Justice Board intended to ensure a more holistic and child-focused approach to managing and safeguarding children at risk of suicide and self-harm.”
The other two deaths are Alex Kelly, 15, who was at Cookham Wood in Kent, and Ryan Clark, 17, who was at Wetherby, West Yorkshire.