A mentally ill prisoner who killed himself after spending two days in jail had told staff he was finding it hard to ignore the “voices” telling him to do so, a report has found.
Michael Berry, 27, was deemed to be “high risk” when he was remanded at HMP Bedford in March 2017, appearing “distressed, hopeless, teary and prone to acting impulsively”, the report notes. Berry was in a “fragile” state and detoxifying from heroin and crack cocaine use.
The report, by the prisons and probation ombudsman, says an officer who completed Berry’s initial reception screening told the investigator he did not have access to any information about the prisoner and based his assessment solely on what Berry told him.
Berry told the officer he had mental health, alcohol and substance misuse issues. After the screening, the officer told a senior officer and a nurse he was concerned that Berry presented a risk of harm to himself. The senior officer completed an immediate action plan indicating that Berry should be observed every 30 minutes.
Berry’s mental health quickly deteriorated, prompting staff to increase his self-harm monitoring to three times every hour.
The report says Berry told staff he could hear voices telling him to kill himself but was trying to ignore them as he wanted to live and did not want to upset his mother. Staff and prisoners said he was “hyper” and “jittery”, and that he appeared to be “arguing with himself” and seemed “tormented”. They heard Berry calling from his cell, although a doctor said the prisoner would not engage with him.
A subsequent check by staff noted Berry was “pacing up and down in his cell and talking to himself”. Around 20 minutes later, he was found to have attempted to kill himself. He was rushed to hospital and died in hospital six days later.
Berry was at Bedford jail having been charged with 22 offences including 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.
He was the eighth prisoner to take their own life at Bedford since 2013.
The watchdog found failings previously identified in the mental health support offered to inmates at the jail had not been properly tackled. The report said it was “concerning” that the reception officer assessed Berry without access to any documentation about his offending history or mental health and that there was no record of an email from the court to the prison explaining Berry’s fragile mental state and the risk of self-harm.
The report recommended that reception officers have access to relevant documentation when assessing new prisoners and that a manager authorises all high-risk assessments.
A Prison Service spokesperson said: “This is a tragic case and our thoughts remain with Mr Berry’s family and friends.
“We accepted all the recommendations from the prisons and probation ombudsman and the prison has since made a number of improvements to the work it does to prevent suicide and self-harm.
“We are rolling out the key worker scheme ensuring that each prisoner has dedicated support from a prison officer and we have also funded the Samaritans helpline for a further three years.”
• In the UK, Samaritans can be contacted on 116 123 or email jo@samaritans.org. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org.
