Daniel Beresford

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Independent investigation into
the death of Mr Daniel Beresford,
a prisoner at HMP Chelmsford,
on 15 October 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 His Majesty’s 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 Daniel Beresford was found hanged in his cell on 13 October at HMP Chelmsford and
died in hospital two days later. He was 36 years old. I offer my condolences to Mr
Beresford’s family and friends.
Mr Beresford’s was the sixth self-inflicted death at Chelmsford since October 2020. To the
end of April 2024, there have been two more self-inflicted deaths since.
Mr Beresford had a significant history of attempted suicide, self-harm and substance
misuse. He appeared to be doing well at Chelmsford and, overall, I am satisfied that there
was little to indicate that he was at imminent risk of suicide in the period leading to his
death. My investigation found an issue with diversion of prescribed medication and some
deficiencies in substance misuse support procedures. I did not find that any of these
issues affected Mr Beresford’s death.
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 May 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 15
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Summary
Events
1. Mr Daniel Beresford had a number of factors that indicated he was at risk of suicide
and self-harm including a significant history of previous suicide attempts, self-harm
and substance misuse. He also had epilepsy, anxiety and depression.
2. Mr Beresford had spent a significant time in prison from 2012. On 20 April 2023, he
was released on licence from HMP Ranby. On 20 June 2023, Mr Beresford was
recalled to HMP Chelmsford having allegedly committed further offences.
3. Mr Beresford’s prescriptions for diazepam and sodium valproate (for anxiety and
epilepsy) were continued and he was put on a methadone maintenance
programme. The Integrated Drug Treatment Service (IDTS) monitored him, and he
received psychosocial substance misuse support from The Forward Trust. Mr
Beresford attended education and the gym and gained a trusted position as a wing
cleaner.
4. In August 2023, healthcare staff reduced Mr Beresford’s diazepam in line with
prescribing guidelines, which Mr Beresford was unhappy about. On 3 September,
Mr Beresford admitted to buying illicit pregabalin on the wing and said he would
continue to do so until he received the correct dose of diazepam.
5. The consultant psychiatrist saw Mr Beresford on 28 September and increased his
diazepam. Mr Beresford subsequently told the IDTS that as a result he was no
longer buying pregabalin.
6. On 9 October, Mr Beresford asked to see the mental health team. A nurse went to
see him the same day, but Mr Beresford said he was not ready to talk. Another
nurse went to see Mr Beresford on 10 October and Mr Beresford again said he did
not want to speak to anyone. The nurse said Mr Beresford appeared happy and
bright.
7. Two of Mr Beresford’s friends said that he had spoken of ending his life in the days
leading to his death, but they did not believe him and did not tell staff.
8. On 8 October, Mr Beresford told his partner on the phone that he would be “in a box
tomorrow”. Mr Beresford’s partner said she spoke to him on the phone on 9, 10 and
11 October and he apologised for what he had said and spoke about starting a
carpentry course. She sent him some money for phone credit so they could speak
over the weekend.
9. One of Mr Beresford’s friends thought he was under the influence of an illicit
substance on 12 October. However, two other prisoners saw him that evening and
said he was his usual self. Post-mortem toxicology tests did not find any illicit drugs
in Mr Beresford’s system.
10. On 13 October at 8.25am, staff found Mr Beresford hanged in his cell. They radioed
a code blue emergency (when a prisoner is having difficulty or has stopped
breathing) and gave Mr Beresford CPR. Paramedics attended and managed to re-
start Mr Beresford’s heart. He was taken to hospital but died on 15 October.
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Findings
11. Mr Beresford did not self-harm during his last period at HMP Chelmsford and
appeared to be settled on his wing. He did well on the graphics course and had a
trusted job. Overall, we consider that there was little to indicate that Mr Beresford
was at imminent or heightened risk of suicide at Chelmsford when he died.
12. Mr Beresford was able to access illicit pregabalin on his wing in September 2023. At
the time, staff shortages meant officers were not supervising the medication
queues. This situation was resolved in January 2024, and we are satisfied the
prison is now actively monitoring medication diversion and taking steps to reduce it.
13. We found some deficiencies in substance misuse support procedures. Mr
Beresford’s full assessment took place eight weeks later than planned, his support
worker did not record their interactions on his clinical record and The Forward Trust
was not invited to integrated drug treatment service (IDTS) meetings. We do not
consider these deficiencies affected the outcome for Mr Beresford.
14. The clinical reviewer concluded that the healthcare offered to Mr Beresford was not
equivalent to that he would have expected in the community. His second health
assessment was eight weeks late and he was not monitored as required during the
five-day opiate withdrawal stabilisation period. She did not consider either of these
factors affected the outcome for Mr Beresford.
15. There was a four-minute delay between staff radioing the code blue and the control
room contacting the emergency services.
Recommendations
• The Head of Healthcare, the Integrated Drug Treatment Service (IDTS) and The
Forward Trust should together ensure that:
• All Forward Trust workers record their interactions with prisoners on both
SystmOne and Nebula;
• Prisoners are informed if there are delays in service provision or
appointments are unable to take place and
• The Forward Trust is invited to IDTS meetings.
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The Investigation Process
16. HMPPS notified us of Mr Daniel Beresford’s death on 15 October 2023.
17. The investigator issued notices to staff and prisoners at HMP Chelmsford informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
18. The investigator visited Chelmsford on 31 October 2023. She obtained copies of
relevant extracts from Mr Beresford’s prison and medical records and watched
CCTV and body worn video camera (BWVC) footage of the emergency response.
She also obtained radio transmissions from 13 October, and recordings of Mr
Beresford’s prison phone calls. Further information was obtained from the Head of
Drug Strategy and The Forward Trust.
19. The investigator interviewed four members of staff and five prisoners in October
and December 2023.
20. NHS England commissioned a clinical reviewer to review Mr Beresford’s clinical
care at the prison. The clinical reviewer jointly interviewed clinical staff with the
investigator.
21. We informed HM Coroner for Essex of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
22. The Ombudsman office contacted Mr Beresford’s partner to explain the
investigation and to ask if she had any matters she wanted him to consider. Mr
Beresford’s partner asked if anyone else had been involved in his death. We have
seen no evidence of third-party involvement. Chelmsford CID also investigated Mr
Beresford’s death on behalf of the Coroner and were satisfied that there was no
third-party involvement. We have sent Mr Beresford’s partner a copy of this report.
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Background Information
HMP Chelmsford
23. HMP Chelmsford is a local prison that takes prisoners directly from the courts.
Castle Rock Group (CRG) Medical provide 24-hour healthcare, including a range of
primary care and secondary mental health services. The Forward Trust provide
substance misuse treatment services.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Chelmsford was in February 2024. Inspectors
found that although Chelmsford remained a challenging jail, staff had worked hard to
reduce drugs and other contraband getting into the prison through improved
security systems and better intelligence gathering This had led to a reduction in the
level of violence and an increase in stability. Drug use was lower than in many
similar jails.
25. Partnership working between prison and health care leaders had improved
considerably, but mental health provision was disjointed and talking therapies were not
being delivered. Prisoners told us that they struggled to get appropriate mental health
support, and many were frustrated by not having some of their basic requests met
Medicine queues were still not being supervised adequately, despite this being
criticised in inspection reports over the last 10 years.
Independent Monitoring Board
26. 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 August 2023, the IMB reported
that incidents of self-harm had increased, and incidents of violence had decreased.
Most prisoners complained to them about missed appointments due to lack of
operational staff to escort them to healthcare and there was a general feeling
among prisoners that there was a lack of healthcare support. The number of key
worker sessions had increased from an average of 90 per month to an average of
630 per month, although prisoners still complained that it was hard for them to
resolve issues.
Previous deaths at HMP Chelmsford
27. There were eight deaths at Chelmsford in the three years before Mr Beresford died.
Five of these were self-inflicted and three were from natural causes. There were no
similarities between those deaths and Mr Beresford’s. Up to April 2024, there had
been two further self-inflicted deaths since that of Mr Beresford.
Emotionally unstable personality disorder (EUPD)
28. Also known as borderline personality disorder, EUPD is characterised by emotional
instability, intense and unstable relationships, impulsive behaviour and negative
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emotions. It is common for people with EUPD to feel suicidal, impulsively self-harm
and engage in reckless activities such as drug misuse.
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Key Events
29. On 28 January 2022, Mr Daniel Beresford was sentenced to four years and two
months’ imprisonment for offences of burglary and theft. It was not his first time in
prison. Mr Beresford had a long history of self-harm and attempted suicide including
fourteen deliberate overdoses of prescribed medication in prison and the
community between 2012 and 2022. He also had a history of accidental overdose.
His prison record (NOMIS) showed that he had been managed under Prison
Service suicide and self-harm monitoring procedures (known as ACCT), on 26
separate occasions since 2013 - most recently in March 2023. Mr Beresford had
tied a ligature round his neck twice, once in 2015 and once in June 2016 when he
was under threat from other prisoners in HMP Lancaster Farms. Mr Beresford also
had a long history of alcohol and substance misuse, epilepsy, anxiety and
depression.
30. Mr Beresford was released on licence from HMP Ranby on 20 April 2023. His
licence was revoked when he allegedly committed further offences of aggravated
vehicle taking and driving while disqualified. Mr Beresford was remanded to custody
and taken to HMP Chelmsford on 20 June 2023.
HMP Chelmsford, 20 June 2023 – 12 October 2023
31. Mr Beresford told an officer that he was happy to be at Chelmsford as he had been
there before and was familiar with the staff. He said he was detoxifying and asked
to see the integrated drug treatment service (IDTS). Mr Beresford said he had a
history of self-harm but was currently in a good place mentally and was aware of
how to access support if he needed it.
32. A nurse completed an initial health assessment. Mr Beresford said he had epilepsy
and misused heroin and crack cocaine. The nurse referred him to the IDTS. Mr
Beresford completed a patient questionnaire which indicated that he might be
dependent on alcohol, but he was not showing signs of withdrawal and his physical
observations were normal. The nurse noted he had a history of self-harm and Mr
Beresford said he had no current thoughts about harming himself.
33. Mr Beresford also saw a nurse from the IDTS team. He said he had been in
Chelmsford before and had been given methadone for his opiate addiction. He told
her that since his release from Ranby, he had been using heroin and crack cocaine
daily and drinking heavily. He said he did not use alcohol or drugs when in prison.
Mr Beresford gave a urine sample which tested positive for cannabis,
benzodiazepines, methadone and cocaine. The nurse completed a Clinical Opiate
Withdrawal Scale (COWS) assessment to measure Mr Beresford’s symptoms of
withdrawal. Mr Beresford scored three, indicating he had no symptoms.
Accordingly, Mr Beresford was not prescribed any medication on his first night.
34. Another nurse from the IDTS reviewed him the next day. Mr Beresford showed
some signs of withdrawal, and she referred him to the GP who prescribed a seven-
day reducing dose of chlordiazepoxide (for alcohol withdrawal) and methadone (for
opiate withdrawal). Mr Beresford was started on a dose of 10ml methadone a day to
be increased by 5ml a day to a maintenance dose of 40ml. The GP also prescribed
him sodium valproate for epilepsy.
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35. Also on 21 June, Mr Beresford completed his induction and moved to F Wing in a
shared cell. On 26 June, he was allocated to part-time education on the graphics
course.
36. Mr Beresford was monitored in line with the IDTS alcohol withdrawal policy for his
first five days at Chelmsford. Clinical monitoring of his opiate withdrawal took place
on only two out of the five days required.
37. On 23 June, a nurse completed an epilepsy care plan. The same day, Mr
Beresford’s cellmate told staff he witnessed him having a seizure. Healthcare staff
attended and completed a Clinical Institute Withdrawal Assessment (CIWA), which
did not indicate that Mr Beresford was suffering alcohol withdrawal. His physical
observations were normal indicating no further clinical action was necessary.
38. On 28 June, Mr Beresford met his Forward Trust substance misuse service
keyworker for a triage assessment. Mr Beresford scored 9/15 on the Severity of
Dependence Scale (SDS) indicating a high level of dependence and a need for
structured treatment. He scored 22/40 on an alcohol audit which indicated an
elevated risk. The keyworker spoke to Mr Beresford about the risks associated with
drinking, how to reduce his consumption and the support networks available. He
also gave Mr Beresford harm minimisation advice on using illicit drugs in prison and
agreed to see Mr Beresford again a week later to complete a full risk assessment.
Mr Bangura recorded the meeting on The Forward Trust case management system
(Nebula) but did not make an entry on Mr Beresford’s clinical record.
39. On 6 July, Mr Beresford a GP that he had taken a number of different medications
for anxiety but only diazepam had worked for him. Mr Beresford’s community
records confirmed that he had a regular prescription of diazepam for anxiety. The
GP restarted Mr Beresford’s prescription and referred him to a psychiatrist for a
medication review.
40. On 17 July, another GP reviewed Mr Beresford’s diazepam prescription and revised
it to a reducing dose. This was in line with prescribing guidelines which state that
diazepam should be prescribed at the lowest possible dose for the shortest period
of time and reviewed regularly with the patient.
41. On 22 July, intelligence was received by the security department that Mr Beresford
had sold some of his prescribed diazepam to another prisoner for vape capsules.
42. On 27 July. Mr Beresford had a key worker session with an officer. He said he was
fine and had no issues.
43. On 1 August, Mr Beresford received a positive behaviour recognition notification for
helping to clean the wing. On 11 August, his graphics tutor recorded that he had
produced excellent work, had been supportive to vulnerable members of the class
and had helped to create a positive attitude in class.
44. On 3 August, Mr Beresford complained to a GP about the reduction of his diazepam
and said he had expected to be on the same dose indefinitely. The GP explained
that no one is on diazepam indefinitely and the dose would continue to be reduced.
45. On 10 August, wing staff called a code blue emergency when Mr Beresford had a
seizure. A prison paramedic responded. When Mr Beresford recovered
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consciousness, he said his diazepam had been stopped (this was not the case, it
had been reduced) and he was worried it would cause him to have more seizures.
Staff put Mr Beresford’s mattress on the floor in case he had another seizure in the
night. His cellmate said he would press the cell bell if he had any concerns and the
night nurse completed regular welfare checks. The paramedic referred Mr
Beresford to a GP for review.
46. The next day, a nurse prescriber reviewed Mr Beresford’s record and continued his
diazepam reduction. At about 10.00pm the same night, Mr Beresford had another
seizure and the night nurse attended, assessed him and completed a set of
physical observations.
47. On 15 August, Mr Beresford had a key worker session with an officer. He said he
was feeling better and had no other concerns. He expressed an interest in
becoming a wing cleaner and the officer advised him to complete a wing worker
application.
48. On 18 August, the nurse prescriber reviewed and continued Mr Beresford’s
diazepam reduction regime. On 23 August, Mr Beresford told him that the diazepam
was being reduced too quickly and he would like to remain on his current dose. The
nurse extended Mr Beresford’s reduction regime by two weeks. Mr Beresford was
due to see the prison psychiatrist on 25 August, but the appointment was
postponed as the psychiatrist was taking part in two-day strike action.
49. On 25 August, Mr Beresford told an officer that he was having increasing thoughts
of harming others. He said he had been rated high risk of sharing a cell in the past
(this was not the case) and wanted to be made high risk again. He said he was
waiting to see the psychiatrist and also asked to see someone from the mental
health team. On 28 August, Mr Beresford moved to F Wing but remained in a
shared cell.
50. On 30 August, Mr Beresford met the substance misuse service keyworker for his
full substance misuse assessment. The keyworker said Mr Beresford seemed in a
good mood and did not raise any issues. He agreed to meet him again in four
weeks. Mr Beresford asked for in-cell packs on heroin and crack cocaine use to
complete in the meantime. The keyworker recorded the meeting on Nebula but did
not make an entry on Mr Beresford’s clinical record.
51. On 3 September, Mr Beresford tested positive for pregabalin (used to treat epilepsy
and anxiety but not prescribed to Mr Beresford) in a random urine test. He admitted
to a member of The Forward Trust that he had been obtaining pregabalin illicitly on
the wing because his diazepam prescription was not managing his anxiety. He
complained that his appointment with the psychiatrist had been cancelled and not
re-booked. She warned Mr Beresford of the dangers of taking illicit medication and
that his methadone might be reduced for his own safety if he continued to take non-
prescribed medication. She completed a security information report. (She was on
long term sick leave during the investigation and was not interviewed.)
52. On 4 September, a nurse recorded that if Mr Beresford took illicit pregabalin again,
staff should tell her as she was a non-medical prescriber (a nurse qualified to
prescribe medication).
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53. On 6 September, the mental health team discussed the waiting list for the
psychiatrist and booked Mr Beresford for another appointment as a medium/high
priority. The Mental Health Team Leader told the clinical reviewer that the national
strike had resulted in a higher than usual number of patients waiting for
appointments. She said that Mr Beresford would not usually have been considered
as a medium or high-risk mental health patient but, as he had missed an
appointment, he was triaged as such to prioritise him for rescheduling.
54. On 11 September, a nurse recorded that Mr Beresford was pacing up and down the
wing stairs talking to himself. She asked him if he was all right and he ignored her.
She tried to talk to him again a minute or so later and he apologised and said he
was not feeling mentally very well. She said Mr Beresford either failed to make eye
contact while talking to her or stared at her intently. She said his speech rambled
and he ruminated on the same things. Mr Beresford said that he was not getting the
correct medication for his mental health and the mental health team were not doing
enough to sort it out. He said he was worried that he would hurt someone if the
issue was not resolved as he had attacked a previous cellmate. He said two
appointments with the psychiatrist had been cancelled (this was not true, it was only
one) and this had increased his anxiety and paranoia.
55. The nurse informed the mental health team and advised wing officers that Mr
Beresford should be in a single cell. She spoke to the orderly officer the next day to
make sure Mr Beresford had been given a single cell and was reassured that the
matter was in hand. She updated Mr Beresford, who thanked her and said that he
was relieved. (She left HMP Chelmsford after Mr Beresford died and the prison was
unable to provide us with her contact details.)
56. On 15 September, Mr Beresford had another key worker session with an officer. He
said he was happy on the wing and enjoyed being a wing cleaner. He said his only
concern was that his medication had been changed and this was causing him to
have seizures. He said he was trying to get a GP appointment. The officer offered
to chase this up for him if he encountered any difficulty getting one. She told us that
Mr Beresford was always polite and chatty and willing to talk.
57. On 17 September, Mr Beresford tested positive for pregabalin. He confirmed to a
member of The Forward Trust that he was still using it illicitly. He said he took it as
and when he could get it because it helped with his anxiety. She warned him again
about the dangers of illicit use. Mr Beresford said he had spent 17 years in prison
and would continue to self-medicate until he received the correct dose of diazepam.
He said he did not care if his methadone was reduced as a precaution. She noted
that Mr Beresford did not show any signs of sedation. She informed a nurse and the
substance misuse team and booked Mr Beresford for another drug test four weeks
later.
58. The same day, Mr Beresford received a positive behaviour recognition notification
from an officer, who said that he was always polite and happy to help, respectful to
staff and prepared to “go the extra mile” in his wing cleaning role.
59. On 18 September, Mr Beresford was due to be discussed in the mental health
triage meeting, but staff ran out of time and agreed to discuss him at the next
meeting on 25 September.
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60. On 19 September, a member of the IDTS saw Mr Beresford for a welfare check. Mr
Beresford said he was happy with his methadone dose and his only concern was
his diazepam prescription. The member advised him to complete a healthcare
application form and request a GP review of his medication. The member said he
discussed harm minimisation with Mr Beresford in detail. Mr Beresford denied any
thoughts of suicide or self-harm and the member be noted that he was able to
articulate his needs well. The next day, Mr Beresford received another positive
behaviour recognition notification for his high standard of cleaning and positive
attitude.
61. On 21 September, healthcare staff added Mr Beresford to the GP waiting list after
he said he was experiencing seizures in the night and had put in an application to
see someone but had not had a reply.
62. On 23 September, a nurse checked Mr Beresford due to his reported night-time
seizures. Mr Beresford’s physical observations were normal, and he said he was
not experiencing headaches or dizziness.
63. On 25 September, staff discussed Mr Beresford in the mental health triage meeting.
The meeting noted he was due for review by the psychiatrist on 28 September.
64. That evening at 6.15pm, an officer radioed a code blue emergency after he
discovered Mr Beresford lying on his floor and shaking. A nurse responded and
assessed him. Mr Beresford was conscious and able to speak but she noted signs
of seizure. Mr Beresford recovered and was given something to eat and drink. The
nurse checked Mr Beresford the next morning. He said he had not had any further
seizures and his physical observations were normal.
65. That afternoon, a nurse attempted to review Mr Beresford’s methadone prescription
in the light of his second positive test for pregabalin. She said initially Mr Beresford
agreed to speak to her in a quiet corner of the wing but when she explained why
she wanted to see him he became dismissive. He told her that everyone from
healthcare was the same and just came to the wing to lie to him and walked off.
66. The nurse said Mr Beresford looked bleary eyed and his speech was slurred. She
said she wondered whether he was under the influence of drugs, although he was
playing chess when she arrived which suggested to her that he was reasonably
alert. She said she tried to persuade Mr Beresford to speak to her, but he would not
engage. She said she was aware of Mr Beresford’s history of overdose and that he
was on more than one medication that might make him drowsy. She therefore
decided to reduce his methadone by 5ml to 35ml as a safety measure. She said
she did not inform the wing staff of her concerns that Mr Beresford was under the
influence.
67. Mr Beresford tested positive for pregabalin at a drug test that day. Staff did not
submit an information report (IR). That evening Mr Beresford refused to take his
epilepsy medication.
68. On 26 September, an Operational Support Grade (OSG) answered Mr Beresford’s
cell bell at about 8.30pm. Mr Beresford said he was feeling unwell and was worried
he might have another seizure. The OSG contacted the night nurse and she said
she would come to the wing when she had finished checking new arrivals in
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reception. She arrived at about 10.00pm, but Mr Beresford refused to see her. He
then changed his mind, and the OSG asked her to come back.
69. A nurse said Mr Beresford said he had fallen out of bed. She cleaned a small cut on
his head, but it did not require a dressing. The nurse asked him why he had refused
his epilepsy medication that evening, and he said that he was not happy that his
dose had changed. (We presume he was referring to his methadone and diazepam
as his epilepsy medication had not changed.) He said he had tried to talk to
healthcare staff, but no one was listening. The nurse gave him his epilepsy
medication, a painkiller for his headache and requested a GP appointment for him.
70. The next day, Mr Beresford again refused to take his epilepsy medication. A nurse
tried to persuade him to change his mind and Mr Beresford said he would discuss it
with the psychiatrist at their appointment the next day.
71. The psychiatrist reviewed Mr Beresford on 28 September as planned. He noted that
Mr Beresford had been referred to him by the GP for long-standing anxiety and a
poor response to a number of standard anxiety treatments including citalopram,
sertraline and mirtazapine. He said Mr Beresford appeared flat and down in mood.
He reported feeling anxious but denied any thoughts of suicide or self-harm. He
agreed to increase Mr Beresford’s diazepam from 2mg once a day to 5mg twice a
day until he could review him again in four weeks. He concluded that Mr Beresford
showed some features of emotionally unstable personality disorder (EUPD). Mr
Beresford said he was happy with the increase in his diazepam and with the
psychiatrist’s plan to review him again in four weeks.
72. The investigator listened to Mr Beresford’s telephone calls from 29 September until
his death. On 4 October, Mr Beresford told his partner that he was not well and felt
in a low mood. He asked her for help with money and she said she was unable to
help him. As the call progressed Mr Beresford contributed less to the conversation
and there were long periods of silence.
73. On 6 October, Mr Beresford told his substance misuse service keyworker that he
was unhappy that his methadone had not been put back to his previous
maintenance dose of 40ml. The keyworker said it had been reduced because Mr
Beresford had tested positive for pregabalin. He explained the dangers of mixing
illicit medication with prescribed medication. Mr Beresford said he was no longer
taking illicit drugs and was starting to feel the positive effects of being abstinent.
The keyworker recorded the meeting on Nebula but did not make an entry on Mr
Beresford’s clinical record.
74. Mr Beresford rang his partner and said that he felt like he was ruining her life, and
her life would be better without him in it. He said he had been in a low mood for a
few weeks.
75. On 8 October, a member from the IDTS team saw Mr Beresford for an IDTS review.
He said he was happy with his dose of methadone and was abstinent from illicit
drugs. Mr Beresford raised no other issues.
76. On 8 October, Mr Beresford spoke to his partner three times. These are the last
calls he made on the prison telephone system. They discussed their relationship.
Mr Beresford said that he did not want to keep letting his partner and son down and
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his partner said he needed to think about whether he was going to change his
behaviour in the future. Mr Beresford said several times over the three calls that his
mental health had deteriorated. At the end of the third call said he could not deal
with his partner anymore as his mental health “was that bad”. He said she would
never have to hear from him again and he would be “in a box tomorrow”. His
partner then ended the call abruptly.
77. A prisoner and friend of Mr Beresford’s said that Mr Beresford had told him a few
days before he died that he “did not want to be here anymore” when they were in
the lunch queue together. He said he told Mr Beresford he was there for him. He did
not tell staff.
78. On 9 October, Mr Beresford did not attend a planned GP appointment for a
medication review. The clinic administrator offered him another one that afternoon,
but Mr Beresford said he did not want to see the GP. The same afternoon a nurse
went to see Mr Beresford after he asked to speak to someone from the mental
health team. Mr Beresford told him that he was not ready to talk, and the nurse put
him on the list to be seen the next day.
79. Another nurse from the mental health team went to see Mr Beresford on 10
October. Mr Beresford apologised and said he did not want to speak to the mental
health team after all. The nurse said Mr Beresford was playing cards with his friends
and appeared to be in a good mood. He said Mr Beresford was “happy and bright”
and told him not to take it personally, but he just did not need to speak to anyone
from the mental health team.
80. On 11 October, a member of the IDTS team said she was on F Wing seeing
another prisoner when Mr Beresford called her over. She said he blamed her for his
methadone being reduced after he had tested positive for pregabalin. Mr Beresford
said he was no longer using illicit pregabalin because his diazepam had been
increased and asked for his methadone to be increased back to 40ml.
81. In a statement to the police made after Mr Beresford died, his partner said Mr
Beresford had called her from a friend’s illicit mobile phone on 9, 10 and 11
October. She said that they had both said sorry for the call on 8 October and she
had sent him some money to top up his phone credit for the weekend. On 11
October, she said Mr Beresford seemed fine. He said he wanted to start a carpentry
course at the prison and was getting on well with the other prisoners. Mr
Beresford’s partner said there was nothing in the call to suggest Mr Beresford was
at risk of suicide.
82. On 12 October, a friend of Mr Beresford’s, who also lived on F Wing, said they had
been due to play chess together, but Mr Beresford was too “high”. The friend said
pregabalin was “everywhere” but the main problem in the prison was psychoactive
substances (known as Spice). Another friend said he had seen Mr Beresford that
evening and there were no signs that Mr Beresford was thinking about harming
himself. He had a coffee with his friend and his cellmate.
83. A prisoner said that Mr Beresford had stopped going to the gym about two weeks
before he died and had been upset in the days leading to his death. In contrast,
another prisoner thought Mr Beresford had been “better than ever”.
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Events of 13 October
84. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to prison radio transmissions from 13 October. She also obtained
information from the East of England Ambulance Service. The following account
has been taken from all sources.
85. At about 7.32am, an officer looked through Mr Beresford’s observation panel as
part of a standard check of every prisoner on F Wing. In his prison statement, the
officer said Mr Beresford was in bed under the covers and clearly breathing.
86. At 8.25am, another officer unlocked Mr Beresford’s cell door and discovered him
suspended from the window by a ligature made from a sheet. She said she tried to
radio a code blue emergency but was unable to get through. She shouted for staff
and another officer radioed a code blue within seconds. Staff supported Mr
Beresford, removed the ligature, laid him on his bed and began cardio-pulmonary
resuscitation.
87. Radio traffic showed that the communications officer phoned for an ambulance at
8.28am, almost four minutes after the code blue was called. He immediately
informed the call handler that Mr Beresford was not breathing which allowed the
emergency to be correctly triaged and an ambulance dispatched with the highest
priority.
88. At 8.28am, a member of staff arrived with the emergency equipment followed within
a minute by a number of nurses. A nurse told an officer to stop CPR so she could
check Mr Beresford’s pulse. He had no pulse, so healthcare staff continued CPR.
They attached a defibrillator and gave Mr Beresford oxygen. The defibrillator did not
detect a shockable heart rhythm and advised them to continue CPR.
89. Staff moved Mr Beresford to the landing and continued treatment. Paramedics
arrived at 8.40am and took over CPR. They gave Mr Beresford adrenaline and
attached a Lucas machine (an automatic chest compression machine). At 8.52am,
Mr Beresford’s heart started beating again and he was taken to hospital.
90. After Mr Beresford was taken to hospital, a prisoner told a member of wing staff that
Mr Beresford had previously told him that he had had enough of being in prison but
did not have the courage to hang himself.
91. Mr Beresford was put on life support in hospital. Subsequent scans showed no
brain activity, life support was withdrawn, and he died on 15 October.
Contact with Mr Beresford’s family
92. At 10.00am on 13 October, the prison chaplain telephoned Mr Beresford’s partner
to tell her he had been taken to hospital and was very unwell. She offered to pay for
a taxi to the hospital, but Mr Beresford’s partner said her family would bring her. Mr
Beresford’s partner arrived at the hospital at 2.20pm. She was present when he
died two days later. The prison offered a financial contribution to Mr Beresford’s
funeral in line with national policy.
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93. Mr Beresford’s partner and her mother accepted an invitation to visit the prison. The
prison held two memorial services for Mr Beresford and prisoners raised a
significant sum of money to be donated to a charity of the family’s choice. The
prison chaplain also attended a separate service held by the family.
Support for prisoners and staff
94. After Mr Beresford was taken to hospital on 13 October, a custodial 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.
95. On 15 October, the prison posted notices informing other prisoners of Mr
Beresford’s death and offering support. Staff reviewed all prisoners assessed as
being at risk of suicide or self-harm in case they had been adversely affected by Mr
Beresford’s death. Listeners (prisoners trained by The Samaritans to provide
confidential peer support) attended F Wing the day after Mr Beresford died.
96. All but one prisoner interviewed said they had received appropriate support after Mr
Beresford’s death. We informed the Head of Safer Custody, and she arranged for
further support to be offered to this prisoner.
Post-mortem report
97. The pathologist gave Mr Beresford’s cause of death as hanging. Toxicology tests
showed the presence of methadone and diazepam at therapeutic levels and the
pathologist concluded that these had not affected Mr Beresford’s death. No
pregabalin or illicit drugs were detected.
Inquest
98. The jury at the Coroner’s inquest held between 25 and 28 April 2025 gave a verdict
of suicide and did not list any contributing factors.
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Findings
Assessment of risk
99. Mr Beresford had a number of factors that indicated he was at risk of suicide and
self-harm including previous suicide attempts, self-harm and substance misuse. In
contrast to his previous periods in prison, Mr Beresford did not attempt suicide or
self-harm at Chelmsford. He appeared to be settled on his wing, had done well on
the graphics course and had a trusted job. Mr Beresford had been concerned about
the reduction of his diazepam, but the psychiatrist increased his dose two weeks
before he died and he appeared happy with that decision. Two prisoners told the
investigator that Mr Beresford had talked about ending his life but did not tell staff.
Although some of Mr Beresford’s friends thought he had been low in mood, others
did not, and his partner had no concerns about him when she last spoke to him on
11 October. We consider that there was little to indicate that Mr Beresford was at
imminent or heightened risk of suicide at Chelmsford before 13 October.
Access to pregabalin
100. Although we have seen no evidence that it affected his death, we are concerned
that Mr Beresford was able to access pregabalin with apparent ease at Chelmsford.
This is most likely to have been diverted medication prescribed to another prisoner.
In their report of a diagnostic support visit to Chelmsford in 2019, HMPPS
Substance Misuse Team identified ample opportunity for prisoners to divert
medication due to a lack of supervision from prison staff. Officer and prisoner focus
groups suggested an issue with trading prescribed medication which was backed
up by the experiences of healthcare staff. Similarly, a supply reduction targeted
support visit in August 2021, identified a need for better supervision of medication
queues to reduce diversion.
101. The Head of Drug Strategy said that during the period Mr Beresford was at
Chelmsford staffing levels had not been sufficiently high to allow officers to
supervise medication administration. On 22 January 2024, the prison implemented
mandatory monitoring of all high trade medications, including pregabalin. Officers
are now required to attend medication hatches to help supervise prisoners.
Prisoners on pregabalin are monitored as part of the monthly prison drug strategy
and medicines management meetings. The pharmacy team monitor incidents of
diversion and submit information reports to the security department. He said
monitoring of medication was still not perfect and he had asked the pharmacist to
develop officer training on monitoring medication and the risks associated with
prisoners using unprescribed medication. The training will be delivered on shutdown
training days.
102. At the time of writing the prison were due to trial a medication pod with a lockable
door and transparent sides. Individual prisoners will be locked in the pod to collect
their medication and only be allowed out once the pharmacist is content they have
taken it appropriately. The pod will be trialled on the induction unit and rolled out to
other wings if successful.
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103. We are satisfied that the prison is now actively monitoring diversion and is taking
appropriate steps to reduce it. We therefore make no recommendation.
Substance misuse support procedures
104. Nine weeks elapsed between Mr Beresford’s Forward Trust triage assessment and
his full assessment – eight weeks later than planned. This was due to staff
shortages, but Mr Beresford was not warned this would be the case. The meetings
with his Forward Trust support worker were not recorded on his clinical record
although they had access to this. Healthcare staff do not have access to Nebula.
This meant that the IDTS team, who were responsible for Mr Beresford’s
methadone maintenance programme, were unsighted on his psychosocial
substance misuse support. The Forward Trust’s Patient Safety Investigation Report
identified these issues and also that management oversight of delays in
assessments was insufficient and Forward Trust support workers were not invited to
IDTS meetings.
105. Effective communication and information sharing is important to all care. Mr
Beresford was prescribed a number of drugs that had a sedative effect and had
admitted to buying illicit medication. It was therefore especially important that
everyone involved in his substance misuse treatment had access to all available
information. Although we cannot say that these issues affected Mr Beresford’s
death, they might prove significant in other cases and so we make the following
recommendation:
The Head of Healthcare, the Integrated Drug Treatment Service (IDTS) and
The Forward Trust should together ensure that:
• All Forward Trust workers record their interactions with prisoners on
both SystmOne and Nebula;
• Prisoners are informed if there are delays in service provision or
appointments are unable to take place and
• The Forward Trust is invited to IDTS meetings.
Clinical Care
106. The clinical reviewer concluded that the healthcare offered to Mr Beresford was not
equivalent to that he would have received in the community because his secondary
health assessment took place some eight weeks after it should have done, and he
was only monitored for opiate withdrawal on two days of the required five-day
stabilisation period. She also concluded that neither of these factors affected Mr
Beresford’s death.
Governor to Note
107. In line with Prison Service Instruction 03/2013, Medical Emergency Response
Codes, Chelmsford use an emergency code system to indicate the seriousness of
an incident to staff. Calling an emergency code should automatically trigger the
control room to call an ambulance. Although staff radioed a code blue as soon as
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Mr Beresford was found hanged, radio traffic and the ambulance call recording
indicated that it was four minutes before the control room contacted the emergency
services, largely because the control room officer appeared busy with other radio
messages. While we cannot say that it affected the outcome for Mr Beresford,
paramedics are experts in resuscitation, have more sophisticated equipment such
as Lucas machines and are able to administer adrenaline. It is therefore crucial that
they are summoned immediately in life threatening situations. The Governor will
want to ensure that this happens in the future.
Good practice
108. The family liaison offered by the prison chaplain in this case was of a high standard.
She went above and beyond what could reasonably be expected, demonstrating a
high degree of empathy and willingness to spend time with Mr Beresford’s family.
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