Christopher Beddall

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Independent investigation into
the death of
Mr Christopher Beddall,
a prisoner at HMP Dovegate,
on 26 February 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist HM Prison and Probation Service (HMPPS) in ensuring the
standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Christopher Beddall was found hanged in his cell at HMP Dovegate on 26 February
2023. He was 40 years old. I offer my condolences to Mr Beddall’s family and friends.
Mr Beddall died just three days after he arrived at Dovegate. During this time, two
important interviews – that should be used to identify any emerging issues for new
prisoners, including about the risk of suicide and self-harm – were not completed.
On the night of his death, Mr Beddall’s statements and actions indicated that his risk had
significantly increased. He threatened to seriously harm himself, made bizarre statements
and blocked the view into his cell. Despite this, wing staff left him unmonitored for over 20
minutes while they waited for the night manager to attend the cell, during which time Mr
Beddall hanged himself.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman October 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
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Summary
Events
1. On 23 February 2023, Mr Christopher Beddall was sentenced to 36 weeks in
prison. It was his first time in custody. Reception staff interviewed and assessed
him on arrival and decided not to start Prison Service suicide and self-harm
prevention procedures (known as ACCT).
2. On 24 February, induction unit officers did not complete a required ‘24-hour’
interview, which includes questions about settling, mood and vulnerabilities. On the
same day, Mr Beddall refused to share a cell with another prisoner and was
charged with a prison disciplinary offence as a result.
3. On 26 February, induction unit officers did not complete the required ‘72-hour needs
analysis’ interview, which includes questions relating to mental health and support
services.
4. At 7.04pm, Mr Beddall pressed the intercom in his cell (which connects with the
staff office) and told an officer that “the Devil was in the cell … you might find a
body”. Another officer went to the cell to speak to Mr Beddall and found that he had
used his shower curtain to block most of the view into the cell. Mr Beddall
threatened to stab himself with a pen and refused to speak further. The officer left
the cell to inform the night manager and start ACCT procedures.
5. At 7.33pm, the night manager arrived at and went into Mr Beddall’s cell. He found
Mr Beddall behind the shower curtain hanged from a ligature. Staff called for
immediate emergency assistance and began cardiopulmonary resuscitation but, at
8.16pm, paramedics confirmed that Mr Beddall had died.
Findings
6. While Mr Beddall had some risk factors for suicide and self-harm when he arrived at
Dovegate, he also had no recorded history of harming himself, was serving a short
sentence, and was not currently receiving treatment for mental ill-health. In the
circumstances, it was not unreasonable that Reception staff chose not to start
ACCT procedures.
7. However, important risk interviews were not completed on Mr Beddall’s first and
third full days in prison. Staff at Dovegate have subsequently reviewed and
identified changes to strengthen and monitor the induction process.
8. On the night of his death, prison staff left Mr Beddall unmonitored for over 20
minutes when circumstances indicated that his risk of suicide and self-harm had
significantly increased.
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The Investigation Process
9. The PPO was notified of Mr Beddall’s death on 26 February 2023. The investigator
issued notices to staff and prisoners at HMP Dovegate informing them of the
investigation and asking anyone with relevant information to contact him. No one
responded. He obtained copies of relevant extracts from Mr Beddall’s prison and
medical records.
10. The investigator interviewed ten members of staff at Dovegate in April 2023.
11. NHS England commissioned a clinical reviewer to review Mr Beddall’s clinical care
at the prison. She jointly interviewed healthcare staff with the investigator.
12. We informed HM Coroner for Staffordshire South of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
13. The Ombudsman’s family liaison officer contacted Mr Beddall’s partner and mother
to explain the investigation and to ask if they had any matters they wanted us to
consider.
14. Mr Beddall’s partner asked us why he was in a cell by himself, whether his mental
ill-health was properly treated in prison, and whether he should have been
monitored under ACCT procedures in the time immediately before his death.
15. Mr Beddall’s mother also asked whether his mental ill-health was properly assessed
and treated. She asked whether prison staff promptly answered Mr Beddall’s
emergency cell bell on the night of his death.
16. We shared the initial report with HM Prison and Probation Service. They did not
identify any factual inaccuracies.
17. We also shared the initial report with Mr Beddall’s partner and mother. Mr Beddall’s
mother identified two factual inaccuracies, which we have amended in this report.
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Background Information
HMP Dovegate
18. HMP Dovegate is a Category B prison in Staffordshire, managed by Serco. The
main prison holds around 930 remanded and sentenced adult prisoners. There is
also a therapeutic community, separate to the main prison, which holds up to 220
prisoners. Practice Plus Group provides 24-hour healthcare services. South
Staffordshire and Shropshire Foundation Trust provides mental health services.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Dovegate was in October 2019. Inspectors
reported that reception processes for new arrivals were efficient and that prisoners
received good support during their early days at the prison. They found that initial
interviews were sufficiently focused on safety and that the induction programme
was comprehensive.
20. Inspectors reported that the number of self-harm incidents had fallen in the six
months before their inspection and was relatively low.
Independent Monitoring Board
21. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to September 2022, the IMB
reported that the number of incidents of self-harm had increased by 11 per cent in
the reporting year, although this was still below pre-pandemic levels. They identified
a slight reduction in the number of times ACCT procedures were started and
reported that this reflected robust ACCT management.
Previous deaths at HMP Dovegate
22. Mr Beddall was the tenth prisoner to die at Dovegate since February 2020, and the
second prisoner to take his own life in that time. There have since been two further
deaths at Dovegate, one of which was self-inflicted. There were no significant
similarities between Mr Beddall’s death and those of the other prisoners.
Assessment, Care in Custody and Teamwork
23. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
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24. As part of the process, support actions are put in place. The ACCT plan should not
be closed until all the support actions have been completed. All decisions made as
part of the ACCT process and any relevant observations about the prisoner should
be written in the ACCT booklet, which accompanies the prisoner as they move
around the prison. Guidance on ACCT procedures is set out in Prison Service
Instruction (PSI) 64/2011.
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Key Events
25. In March 2019, Mr Christopher Beddall reported suicidal thoughts and symptoms of
depression and anxiety. A community GP prescribed antidepressants. In January
2020, following an episode of drug-induced psychosis, he was detained in a
psychiatric hospital for two weeks under the Mental Health Act, during which time
he was diagnosed with mania with psychotic symptoms. Mr Beddall was prescribed
antipsychotics on his release.
26. In 2021, Mr Beddall did not attend several appointments with his community mental
health team and was subsequently discharged from their service. He was no longer
prescribed antipsychotics, and his antidepressant prescription was stopped at
around the same time.
23 February 2023
27. On 23 February 2023, Mr Beddall was sentenced to 36 weeks in prison for
possessing a bladed article in a public place. This was his first time in prison.
28. Court staff completed a Person Escort Record (PER, a form that accompanies
prisoners on all journeys to communicate information, including about risk factors)
and recorded that Mr Beddall had no risk of suicide and self-harm, no current drug
or alcohol issues and no health issues.
29. In the afternoon, Mr Beddall arrived at HMP Dovegate. A Prison Custody Officer
(PCO) completed a reception interview. He noted that Mr Beddall did not arrive with
a suicide and self-harm warning form. He recorded that Mr Beddall said that he had
never previously harmed himself and had no current thoughts to do so.
30. The PCO also completed a cell sharing risk assessment (CSRA, a form designed to
assess the risk of violence a prisoner poses to a potential cellmate). He concluded
that Mr Beddall’s risk of severe cell violence was standard (on a scale of standard
and high).
31. A nurse conducted an initial health assessment. She recorded that Mr Beddall
described his previous psychiatric admission but said that he did not have any
acute mental health issues. Mr Beddall said that his previous admission was due to
a “drug induced psychosis”. He denied any current drug issues but said that he
drank rum most days. (She completed a check of alcohol withdrawal symptoms and
recorded that Mr Beddall did not have any signs of withdrawal.)
32. The nurse recorded that Mr Beddall said that he had no thoughts of suicide and
self-harm and no history of harming himself. She noted that it was Mr Beddall’s first
time in prison and that he said that his relationship with his partner had recently
broken down. The nurse recorded that Mr Beddall was not currently prescribed any
medication, but that he complained of pain in his ribs following an incident three
weeks earlier. She referred him to the mental health team, to the alcohol brief
intervention service, and asked for a doctor to prescribe pain relief.
33. When he arrived on M Wing, the induction unit, Mr Beddall refused to share a cell
with another prisoner. He was allocated the single occupancy of a double cell.
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24 February 2023
34. On 24 February, a doctor at the prison prescribed naproxen for Mr Beddall’s rib
pain.
35. As part of the induction process, an officer is required to complete a ’24-hour’
interview on a prisoner’s first full day in custody. This includes questions about
mood, behaviour, how they have settled and any vulnerabilities. No one completed
Mr Beddall’s interview. When Mr Beddall arrived at Dovegate, an officer on the
induction unit was required to conduct this interview.
36. At around 9.45am, a nurse completed Mr Beddall’s secondary health assessment.
She recorded that there were no healthcare concerns, and that Mr Beddall had no
thoughts of suicide or self-harm.
37. At around 10.40am, a Healthcare Assistant (HCA) and two colleagues completed
an alcohol screening for Mr Beddall. She told us that Mr Beddall was socialising
with other prisoners and appeared to be in good spirits. She recorded that Mr
Beddall did not have any withdrawal symptoms and did not require an alcohol
detox. She noted that when one of her colleagues asked Mr Beddall about his
sentence, he said that he intended to “buy a machine gun and explosives to target
the police station and judge who put him here”. The HCA told us that Mr Beddall did
not appear angry or upset when he said this and that he did not appear to have any
symptoms of mental ill-health. She said that it was “more of a passing comment
than anything”. She completed a security intelligence report.
38. A security officer assessed the intelligence report. They recorded that it was likely to
have been said in frustration at being in prison and that it was not known whether
Mr Beddall was capable of carrying out such an attack.
39. At around 3.00pm, a PCO told Mr Beddall that he was required to share a cell with
a particular prisoner. Mr Beddall refused. He told us that Mr Beddall did not give a
reason why he would not share, but that it was a relatively common occurrence for
prisoners to refuse. He said that Mr Beddall became angry and threw an object at
the cell door. He charged Mr Beddall with the disciplinary offence of disobeying a
lawful order.
40. The PCO told another PCO about Mr Beddall’s refusal to share. She spoke to Mr
Beddall at his cell and told us that he said that he would “rip somebody’s head off” if
he had to share a cell. She said that she then left Mr Beddall to calm down, but that
he apologised to her later that afternoon. Mr Beddall then said that he did not want
to share a cell because he experienced “mental health and schizophrenia”. She did
not make a referral to the mental health team.
41. A PCO completed a conduct report for Mr Beddall’s disciplinary hearing. She
recorded that Mr Beddall conformed with the regime, interacted well with other
prisoners and had not caused any concerns for staff.
25 February 2023
42. On 25 February, an operational manager chaired Mr Beddall’s disciplinary hearing.
She recorded that wing staff reported to the adjudication liaison officer that Mr
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Beddall was “feeling unwell due to his mental health” and would not therefore attend
the hearing. She adjourned the hearing for a review of Mr Beddall’s mental health.
(A nurse had made a routine mental health referral from Reception, which meant
that Mr Beddall should be assessed within five working days of his arrival, which
was 2 March.)
43. In the afternoon, a HCA completed substance misuse observations and recorded
that Mr Beddall reported no concerns other than “feeling a bit shaky”.
44. Mr Beddall made two telephone calls to his partner and one call to his son.
(Prisoners at Dovegate have telephones in their cells. All calls are recorded, and
staff listen to a random sample for security monitoring. No one listened to Mr
Beddall’s calls until after his death.) In calls to his partner, Mr Beddall said that he
expected to have a year or two added to his sentence. (In this and in later calls, Mr
Beddall told his partner and family that he was due in court on 3 March 2023. Prison
staff told us that they had no record of this or any other future court dates.) Mr
Beddall asked his partner to speak to his solicitor about a psychiatric report as he
said that his issues were mental health, drug and alcohol-related.
26 February 2023
45. An officer from the induction unit is required to complete a ’72-hour needs analysis’
on a prisoner’s third full day in custody. The document includes questions about
mental health issues, support provided during the induction process, conflicts with
other prisoners and access to the Samaritans and Listeners. No one completed Mr
Beddall’s 72-hour interview.
46. At 5.08pm, a PCO locked Mr Beddall’s cell door for the night. She said that they
had a brief conversation about a chair outside Mr Beddall’s cell (which he had used
earlier while watching other prisoners playing pool) and that Mr Beddall said that he
was “fine”.
47. At 5.10pm, Mr Beddall telephoned his partner. He told her that he was due in court
on 3 March and that he might get an additional two-year sentence. Mr Beddall said
that he would “try to get in a mental hospital” if this were to happen. He said that he
“shouldn’t be in here … I’m fucked in the head … I’m holding it together for you and
the kids”. Mr Beddall said that he had “major psychiatric issues” but was “hiding
them through humour”.
48. Mr Beddall told his partner that he would see a doctor the next day to obtain
quetiapine (antipsychotic medication), which he intended to trade for a vape. He
discussed future visits and said that he had applied for jobs in prison.
49. At 5.27pm, Mr Beddall telephoned his son and daughter. He told them that if he was
given an additional sentence on 3 March he would “go mental and get put in a
mental hospital and escape”. Mr Beddall said that he had “been hiding [my mental
health issues] through humour”.
50. At 6.45pm, Mr Beddall made a 13-minute telephone call to his partner. He spoke
about his arrest and said that he had been “sleep deprived and under the influence
of alcohol”. Mr Beddall said that he “went out with a knife because I wanted
someone to kill me … I didn’t intend to harm anyone”. He said that he was “taken to
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the nut house” when he was arrested and “bullshitted” them, so he was not
admitted. (There is no reference in Mr Beddall’s prison or medical records of a
potential psychiatric admission when he was arrested.) Mr Beddall said that he
expected to get an additional two-year sentence and that he believed that his
actions did not warrant this. He told his partner that he would call her again the next
day.
51. At 7.04pm, Mr Beddall pressed the intercom in his cell. (Prisoners on M Wing can
communicate with the staff office through an intercom system.) PCO A answered.
He told us that Mr Beddall said, in a raised voice, that “the Devil was in the cell …
you might find a body”. PCO B, who was also in the staff office, said that she would
go to the cell to speak to Mr Beddall.
52. At 7.10pm, PCO B arrived at Mr Beddall’s cell and spoke to him through the
observation panel for just over a minute. She said that Mr Beddall had tied his
shower curtain across the width of the cell to block off the sleeping area and that
she could only see the bottom of his legs behind the curtain. When she opened the
observation panel, Mr Beddall came to the door and said “I’ll stick a pen in my neck”
before moving back behind the shower curtain. She said that she tried to get Mr
Beddall to engage with her, but he said, “I don’t want to talk to anybody”. She
decided to notify the night manager and to start ACCT procedures.
53. When PCO B returned to the office, PCO A agreed to contact the duty manager, a
Custodial Operations Manager (COM), while she began to complete an ACCT
document. The COM told us that he said that he advised PCO A that he would visit
the unit to speak to Mr Beddall. He said that he did not give the staff any
instructions on how to manage Mr Beddall’s risk before he arrived.
54. PCO B said that there were no blank ACCT documents in the office, so she had to
go to another area of the prison to obtain one. (She said that she first went to
Reception, where there were also no blank documents, and then to the Safer
Custody office to obtain an ACCT document. She returned to the office after the
COM had arrived on the wing.)
55. At 7.31pm, the COM and the deputy night manager arrived on M Wing. The COM
went to the cell of an Insider (an experienced prisoner who lives on the induction
wing to help and advise new arrivals into prison) to ask him how Mr Beddall had
been during the day. He told us that the Insider said that there was nothing out of
the ordinary.
56. At 7.33pm, the COM arrived at and went into Mr Beddall’s cell, followed by the
deputy night manager and PCO C. They found Mr Beddall sitting on the floor behind
the shower curtain, with a ligature around his neck made from a belt and tied to the
bed frame. The PCO radioed a medical emergency code blue, indicating a life-
threatening situation, while the COM and the deputy night manager cut the ligature
and began cardiopulmonary resuscitation.
57. At 7.36pm, two nurses arrived and supervised the resuscitation. At 7.58pm,
paramedics arrived at Mr Beddall’s cell and, at 8.16pm, they confirmed that he had
died.
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Contact with Mr Beddall’s family
58. At 1.10am on 7 February, two prison family liaison officers visited Mr Beddall’s
partner and informed her of his death. Dovegate contributed to funeral costs in line
with national policy.
Support for prisoners and staff
59. After Mr Beddall’s death, an operational manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
60. The prison posted notices informing other prisoners of Mr Beddall’s death and
offering support. All prisoners being monitored under ACCT procedures were
observed more frequently in the time after Mr Beddall’s death, and a manager was
assigned to offer additional support to them.
Post-mortem report
61. A post-mortem examination identified the cause of death as hanging.
62. Mr Beddall’s mother asked us about a white powder that was found in his pocket
after his death. Toxicology tests identified that this was coffee whitener.
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Findings
Identifying the risk of suicide and self-harm
63. PSI 64/2011, which governs ACCT suicide and self-harm prevention procedures,
requires all staff who have contact with prisoners to be aware of the risk factors and
triggers that might increase the risk of suicide and self-harm and take appropriate
action. Any prisoner identified as at risk of suicide or self-harm must be managed
under ACCT procedures. We have considered whether staff at Dovegate should
have identified Mr Beddall as at risk and begun ACCT procedures to support him.
Reception
64. PSI 64/2011 recognises that prisoners are at increased risk of suicide and self-harm
in their first days in custody. Mr Beddall had some other risk factors for suicide and
self-harm when he arrived at Dovegate: it was his first time in prison, and he had
previously been detained in a psychiatric hospital. However, Mr Beddall had no
recorded history of self-harm and was subject to a short prison sentence (with a
potential release date of a little over two months). He was not currently under the
care of community mental health services or prescribed medication for mental ill-
health. Reception staff noted this information and the reception nurse made
appropriate referrals. In the circumstances, it was reasonable that reception staff
chose not to start ACCT procedures when Mr Beddall first arrived at Dovegate.
65. The reception nurse made a routine referral to the mental health team, based on Mr
Beddall’s reported history of psychiatric admission. This meant that he should be
assessed within five working days of arrival (which was 2 March 2023). The clinical
reviewer concluded that this was the appropriate decision, based on Mr Beddall’s
presentation and the information available at the reception health screen.
Director to Note
Day one and day three assessments
66. Some aspects of early days risk assessment were not completed in line with local
expectations. The required ’24-hour’ and ’72-hour needs analysis’ interviews were
not completed. This meant that prison staff did not give themselves the best
opportunity to assess how Mr Beddall had settled into prison or to identify whether
he had any ongoing or emerging issues. Had these interviews been carried out,
they might have helped staff to identify and address any uncertainty about future
court attendance or consider further his reasons for not sharing a cell.
67. A COM started as Early Days in Custody Manager two days before Mr Beddall died.
Before this, there was not an assigned manager for Early Days and the role was
overseen by several managers who shared it with other duties. Following Mr
Beddall’s death, the COM reviewed 24-hour and 72-hour interviews for other
prisoners and identified further occurrences when the interviews were not
completed.
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68. The COM has since changed the process so that a manager, rather than an officer,
must complete the 24-hour interview. An induction unit officer will still complete the
72-hour interview, but if no permanent induction officer is available, a manager will
complete the interview (rather than an officer from elsewhere in the prison). He also
explained that he now reviews all induction paperwork on a weekly and monthly
basis to identify whether any stages have been missed.
69. We are satisfied that the induction interview process has been appropriately
reviewed and amended following Mr Beddall’s death. The Director will want to
ensure that managers continue to review and monitor the completion of these
important interviews.
Evening of 26 February 2023
70. Mr Beddall’s comments and actions from 7.00pm on 26 February indicated a
potentially significant increase to his risk of suicide and self-harm. He spoke about
seeing the “Devil” in his cell, threatened to stab himself with a pen and blocked the
view into his cell.
71. PCO B appropriately went to the cell when Mr Beddall first made unusual
comments on the intercom. At the cell, Mr Beddall said little, other than threatening
to harm himself, and he had positioned the shower curtain seemingly to block the
view into the cell.
72. An HMPPS Safety Briefing on Observation Panels, issued in February 2018, states
that when staff discover that a panel has been blocked, and the prisoner does not
comply with instructions to remove the blockage, they must take immediate action
to remove the obstruction and check on the prisoner’s welfare. When a prisoner has
been identified as at risk of suicide and self-harm, it is especially important that staff
take immediate action. PSI 64/2011 states that when the risk of harm is imminent,
action to keep the prisoner safe and under supervision will take priority over
completing the initial sections of the ACCT document.
73. While PCO B could see Mr Beddall’s feet, his actions and words indicated that he
might be at high risk of suicide and self-harm. She appropriately concluded that she
should start ACCT procedures and alert the night manager. While we are satisfied
that she acted with Mr Beddall’s best interests in mind and with the intention of
taking immediate actions to manage his risk, hindsight also indicates that she could
have remained at Mr Beddall’s cell until the night manager attended.
Inquest
74. The inquest into Mr Beddall’s death concluded on 26 March 2025, and concluded
that Mr Beddall died from self-inflicted hanging without an attempt to end his life.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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