This is a media release by Ison Harrison, reshared by INQUEST
Inquest hearing at Council Chamber, The Council House, Old Market Square, Nottingham between 7 - 15 October 2024, before HMAC Michael Wall with a Jury
Jury found that multiple failings by Prison and Healthcare staff contributed to the self-inflicted death of Mark Beresford
Mark Steven Beresford was a much-loved son and fiancé and died by self-inflicted means on 7th July 2023 at Bassetlaw Hospital in Nottinghamshire following a ligature attempt on 3 July 2023 at HMP Ranby. He was transferred on 11 April 2023 from HMP following concerns about prisoners at HMP Nottingham.
Mark had a history of anxiety, depression, and paranoia, sometimes presenting as irrational suspicion and mistrust of others. To cope with intrusive thoughts, he resorted to self-harm. During his time at both HMP Nottingham and HMP Ranby, Mark engaged in numerous acts and threats of self-harm, varying in severity. It was generally agreed that these incidents were intended to relieve anxiety and intrusive, paranoid thoughts, rather than as genuine suicide attempts. Notably, his actions were often preceded by pressing his cell bell, which triggered interventions to ensure his safety. The risks associated with ligature use were well-known to both prison and healthcare staff.
On 6 March 2023, Mark swallowed razor blades following an altercation with his cellmate. He was then placed on the prison’s suicide and self-harm monitoring process, known as the Assessment, Care in Custody, and Teamwork (ACCT) program. He remained under ACCT monitoring until May 2023, sometimes under constant supervision.
Mark’s attempts at self-harm continued, including by ligaturing.
At the time of his transfer, Mark had an open referral for a psychiatric assessment. However, at HMP Ranby’s Mental Health Assessment meetings, staff failed to fully review available information indicating that Mark might be experiencing symptoms of drug-induced psychosis and did not appreciate the ongoing risk of self-harm. He was subsequently discharged from the mental health team, meaning there was no psychiatric assessment or intervention. He was also non-compliant with his anti-depressant medication, ostensibly due to anxiety associated with waiting in the medication review process.
This specific failing regarding Mark’s case was part of a broader, systemic issue in which patients with significant self-harm risks were not automatically referred for psychiatric multidisciplinary team (MDT) discussions.
After his discharge from the mental health team on 20th April, Mark continued to self-harm. As his release date approached, he grew increasingly anxious about potential retribution from his cellmates.
On 2nd July 2023, at 12:39, Mark activated his cell bell and informed a prison officer that "his ACCT should not have been closed and he wanted to hang himself." The ACCT process was reopened; however, later that day, Mark was found ligatured on the prison wing landing. Despite this further act of self-harm, his risk and observation levels were not adjusted.
The next morning, on 3rd July, the ACCT was reviewed and closed without discussing the self-harm events of the previous day.
Later on 3rd July, Mark activated his cell bell at 11:42, 11:47, and 12:06 pm. After the third bell, a prison officer observed through the cell window that Mark preparing to ligature. His ACCT was reopened just hours after it had been closed, but the officer admitted unfamiliarity with the process. Senior prison staff failed to implement an ‘Immediate Action Plan’ (IAP), a mandatory plan to be completed within one hour of reopening an ACCT to ensure the individual’s safety until a formal review. Mark’s observations were set at two-hour intervals.
At 12:53 pm on 3rd July, Mark pressed his cell bell. Due to an administrative oversight by a senior officer, there was no cover for the area of the wing where Mark’s cell was located. The failure to complete an IAP and the lack of staff available to respond to cell bells during the lunchtime period meant that Mark was neither observed nor spoken to from approximately 12:15 pm.
His cell bell went unanswered until 1:26 pm. At 1:25 pm, a fellow prisoner alerted staff, who found Mark having ligatured and unresponsive. CPR was unsuccessful in preventing significant hypoxic brain damage, and doctors at Bassetlaw General Hospital confirmed there was no chance of recovery. Care was subsequently withdrawn, and Mark sadly passed away on 7th July 2023.
Both HMP Ranby and Nottinghamshire Healthcare Trust admitted to multiple failings in this case.
Coroner’s Conclusion as to Death - Misadventure and Narrative Conclusion
The Coroner reviewed the evidence on a point-by-point basis for the Jury, citing the acknowledged failings of both the healthcare trust and the prison service. The Coroner directed that there was insufficient evidence to conclude suicide. In response to a structured questionnaire, the Jury identified multiple causative failings, most of which had been openly admitted during the inquest.
The Jury concluded that Mark died as a result of misadventure on 7th July 2023. When he performed the act that led to his death on 3rd July 2023, he was experiencing significant mental ill health. The decision by healthcare staff to discharge Mark from mental health team care on 20th April 2023, without referral to the psychiatric MDT, was deemed unreasonable in all circumstances. An admitted failure also occurred at HMP Ranby in assessing the nature and extent of Mark’s mental health issues.
When Mark’s ACCT was reopened on 2nd July 2023, the decision by prison staff to set observation intervals at no more than every two hours was also deemed unreasonable. Following the second self-harm incident on 2nd July, the failure to increase observation levels was further identified as an unreasonable action. Both healthcare and prison staff admitted that the assessment of Mark’s risk and the decision to close the ACCT on 3rd July 2023 were unreasonable in the circumstances.
When the ACCT was reopened again around noon that day, the decision by prison staff to leave the observation intervals unchanged was also unreasonable. Additionally, prison staff admitted to failing to complete the Immediate Action Plan within the required hour, if at all. Staff acknowledged the failure to respond promptly to the cell bell Mark activated at 12:53, which remained unanswered for approximately 33 minutes until he was found unresponsive at 1:26 pm.
The prison service admitted there was a management failure to ensure adequate staffing to respond to cell bells in Mark’s area during the lunch period. The Jury determined that all these failings contributed to Mark’s death by misadventure.
They further stated that “several missed opportunities and ineffective communications between all parties involved with Mark included, but were not limited to, inadequate checks of notes across various systems, ineffective information sharing, weaknesses in collaborative practices, lack of broader thinking, and a tendency to address only the visible symptoms.”
Mark's mother remembers him as a kind and gentle beloved family member who would always make them laugh. As a child, Mark enjoyed sports, music, and spending time with his mother and sisters. His mother remembers him as having a “heart of gold” and recalls his love for working with animals and nature. His partner Gail is bereft at the loss of the man she planned to spend the rest of her life with. Mark’s whole family are devastated by the tragic loss that was entirely preventable
The Coroner noted that he had concerns about the evidence from the prison and indicated he would be issuing a Prevention of Future Deaths Report
Jenny Croston, of Ison Harrison Solicitors, representing the family said:
“This is a tragic and deeply troubling case involving the death of a much loved young man whilst a prisoner at HMP Ranby which unquestionably should have been avoided. His death identifies serious flaws in the management of prisoners who are vulnerable because of their mental health and at risk of, self-harm.
The ACCT process is extremely important in a prison setting to ensure the safety of individuals at risk and it is worrying that officers responsible for conducting ACCT on fail grasp the importance of these processes. We are grateful to the Coroner and the jury for their consideration of failings again identified at this inquest which are strikingly familiar to other deaths. We are grateful for the indication of Prevention of Future Deaths report from the Coroner in due course."
ENDS
NOTES TO EDITORS
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Mark Beresford: Jury Find Multiple Failings Contributed To Self-inflicted Death In Hmp Ranby
CONTENT WARNING: Please read with care as this page may involve information on death, suicide, mental illness, disability, state neglect, and police and prison violence that some people may find upsetting. If you need support, please visit our support page.
This is a media release by Ison Harrison, reshared by INQUEST
Inquest hearing at Council Chamber, The Council House, Old Market Square, Nottingham between 7 - 15 October 2024, before HMAC Michael Wall with a Jury
Jury found that multiple failings by Prison and Healthcare staff contributed to the self-inflicted death of Mark Beresford
Mark Steven Beresford was a much-loved son and fiancé and died by self-inflicted means on 7th July 2023 at Bassetlaw Hospital in Nottinghamshire following a ligature attempt on 3 July 2023 at HMP Ranby. He was transferred on 11 April 2023 from HMP following concerns about prisoners at HMP Nottingham.
Mark had a history of anxiety, depression, and paranoia, sometimes presenting as irrational suspicion and mistrust of others. To cope with intrusive thoughts, he resorted to self-harm. During his time at both HMP Nottingham and HMP Ranby, Mark engaged in numerous acts and threats of self-harm, varying in severity. It was generally agreed that these incidents were intended to relieve anxiety and intrusive, paranoid thoughts, rather than as genuine suicide attempts. Notably, his actions were often preceded by pressing his cell bell, which triggered interventions to ensure his safety. The risks associated with ligature use were well-known to both prison and healthcare staff.
On 6 March 2023, Mark swallowed razor blades following an altercation with his cellmate. He was then placed on the prison’s suicide and self-harm monitoring process, known as the Assessment, Care in Custody, and Teamwork (ACCT) program. He remained under ACCT monitoring until May 2023, sometimes under constant supervision.
Mark’s attempts at self-harm continued, including by ligaturing.
At the time of his transfer, Mark had an open referral for a psychiatric assessment. However, at HMP Ranby’s Mental Health Assessment meetings, staff failed to fully review available information indicating that Mark might be experiencing symptoms of drug-induced psychosis and did not appreciate the ongoing risk of self-harm. He was subsequently discharged from the mental health team, meaning there was no psychiatric assessment or intervention. He was also non-compliant with his anti-depressant medication, ostensibly due to anxiety associated with waiting in the medication review process.
This specific failing regarding Mark’s case was part of a broader, systemic issue in which patients with significant self-harm risks were not automatically referred for psychiatric multidisciplinary team (MDT) discussions.
After his discharge from the mental health team on 20th April, Mark continued to self-harm. As his release date approached, he grew increasingly anxious about potential retribution from his cellmates.
On 2nd July 2023, at 12:39, Mark activated his cell bell and informed a prison officer that "his ACCT should not have been closed and he wanted to hang himself." The ACCT process was reopened; however, later that day, Mark was found ligatured on the prison wing landing. Despite this further act of self-harm, his risk and observation levels were not adjusted.
The next morning, on 3rd July, the ACCT was reviewed and closed without discussing the self-harm events of the previous day.
Later on 3rd July, Mark activated his cell bell at 11:42, 11:47, and 12:06 pm. After the third bell, a prison officer observed through the cell window that Mark preparing to ligature. His ACCT was reopened just hours after it had been closed, but the officer admitted unfamiliarity with the process. Senior prison staff failed to implement an ‘Immediate Action Plan’ (IAP), a mandatory plan to be completed within one hour of reopening an ACCT to ensure the individual’s safety until a formal review. Mark’s observations were set at two-hour intervals.
At 12:53 pm on 3rd July, Mark pressed his cell bell. Due to an administrative oversight by a senior officer, there was no cover for the area of the wing where Mark’s cell was located. The failure to complete an IAP and the lack of staff available to respond to cell bells during the lunchtime period meant that Mark was neither observed nor spoken to from approximately 12:15 pm.
His cell bell went unanswered until 1:26 pm. At 1:25 pm, a fellow prisoner alerted staff, who found Mark having ligatured and unresponsive. CPR was unsuccessful in preventing significant hypoxic brain damage, and doctors at Bassetlaw General Hospital confirmed there was no chance of recovery. Care was subsequently withdrawn, and Mark sadly passed away on 7th July 2023.
Both HMP Ranby and Nottinghamshire Healthcare Trust admitted to multiple failings in this case.
Coroner’s Conclusion as to Death - Misadventure and Narrative Conclusion
The Coroner reviewed the evidence on a point-by-point basis for the Jury, citing the acknowledged failings of both the healthcare trust and the prison service. The Coroner directed that there was insufficient evidence to conclude suicide. In response to a structured questionnaire, the Jury identified multiple causative failings, most of which had been openly admitted during the inquest.
The Jury concluded that Mark died as a result of misadventure on 7th July 2023. When he performed the act that led to his death on 3rd July 2023, he was experiencing significant mental ill health. The decision by healthcare staff to discharge Mark from mental health team care on 20th April 2023, without referral to the psychiatric MDT, was deemed unreasonable in all circumstances. An admitted failure also occurred at HMP Ranby in assessing the nature and extent of Mark’s mental health issues.
When Mark’s ACCT was reopened on 2nd July 2023, the decision by prison staff to set observation intervals at no more than every two hours was also deemed unreasonable. Following the second self-harm incident on 2nd July, the failure to increase observation levels was further identified as an unreasonable action. Both healthcare and prison staff admitted that the assessment of Mark’s risk and the decision to close the ACCT on 3rd July 2023 were unreasonable in the circumstances.
When the ACCT was reopened again around noon that day, the decision by prison staff to leave the observation intervals unchanged was also unreasonable. Additionally, prison staff admitted to failing to complete the Immediate Action Plan within the required hour, if at all. Staff acknowledged the failure to respond promptly to the cell bell Mark activated at 12:53, which remained unanswered for approximately 33 minutes until he was found unresponsive at 1:26 pm.
The prison service admitted there was a management failure to ensure adequate staffing to respond to cell bells in Mark’s area during the lunch period. The Jury determined that all these failings contributed to Mark’s death by misadventure.
They further stated that “several missed opportunities and ineffective communications between all parties involved with Mark included, but were not limited to, inadequate checks of notes across various systems, ineffective information sharing, weaknesses in collaborative practices, lack of broader thinking, and a tendency to address only the visible symptoms.”
Mark's mother remembers him as a kind and gentle beloved family member who would always make them laugh. As a child, Mark enjoyed sports, music, and spending time with his mother and sisters. His mother remembers him as having a “heart of gold” and recalls his love for working with animals and nature. His partner Gail is bereft at the loss of the man she planned to spend the rest of her life with. Mark’s whole family are devastated by the tragic loss that was entirely preventable
The Coroner noted that he had concerns about the evidence from the prison and indicated he would be issuing a Prevention of Future Deaths Report
Jenny Croston, of Ison Harrison Solicitors, representing the family said:
“This is a tragic and deeply troubling case involving the death of a much loved young man whilst a prisoner at HMP Ranby which unquestionably should have been avoided. His death identifies serious flaws in the management of prisoners who are vulnerable because of their mental health and at risk of, self-harm.
The ACCT process is extremely important in a prison setting to ensure the safety of individuals at risk and it is worrying that officers responsible for conducting ACCT on fail grasp the importance of these processes. We are grateful to the Coroner and the jury for their consideration of failings again identified at this inquest which are strikingly familiar to other deaths. We are grateful for the indication of Prevention of Future Deaths report from the Coroner in due course."
ENDS
NOTES TO EDITORS
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
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