Michael Berry
PFD Report
Historic (No Identified Response)
Ref: 2018-0157
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
2 Sep 2018
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
(1) Michael was in Healthcare Cell number which throughout the Inquest was described variously as 'Reduced Risk Cell" or "Safer Cell" . It appears that in fact it is not reduced risk cell but more a 'Half Way House" in that the furniture is fixed to the floor. In the cell, however there was a very obvious ligature point that could be avoided, namely the window, which opens inwardly: On the face of it there would appear to be many design solutions that would overcome the need for an opening window that provides such an obvious ligature point:
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
Report Sections
Investigation and Inquest
On 17 March 2017 commenced an Investigation into the death of Michael BERRY, aged 34 years. The Investigation concluded at the end of the Inquest on 16 May 2018. The Conclusion of the Inquest was that Michael deliberately chose to suspend himself but the evidence did not fully explain whether or not he intended the outcome to be fatal. The medical cause of death was: Global hypoxic brain injury Hanging Depression
Circumstances of the Death
The Deceased was found hanging from a sheet in the Medical Wing of Bedford Prison on 10 March 2017 . When found, he was unresponsive with no palpable pulse and his pupils were unreactive. He received basic life support from the prison staff who achieved return of spontaneous circulation. He was intubated at the scene by the Helicopter Emergency Medical Services Team. Following this he was transferred to Bedford Hospital and admitted to the Critical Care Unit where he remained intubated and ventilated.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.