This is a media release by Ison Harrison, reshared by INQUEST
Before HM Area Coroner Michael Wall
Nottinghamshire Coroner’s Court
Inquest heard 7 – 15 October 2024
Prevention of Future Deaths report 25 October 2024
Following the Inquest into the death of Mark Beresford, HMAC Michael Wall delivered a scathing Prevention of Future Deaths report (PFD) to HMP Ranby. Of note he recorded that on two occasions, evidence given by a member of senior management was “incorrect and liable to mislead the jury and the coroner.”
Mark died on 7 July 2023 by self-inflicted means. The jury recorded that his death was by misadventure, but with with a damming narrative conclusion that identified several causative failings by both HMP Ranby and Nottingham Healthcare Trust.
Evidence was heard from senior management, Head of Operations at HMP Ranby, in relation to changes to the systems, policies and training after failings previously identified in the Prisons and Probation Ombudsman’s (PPO) Report following Mark’s death.
Evidence from same witness contradicted evidence previously given by staff from HMP Ranby involved in the circumstances surrounding Mr Beresford’s death.
The Coroner was “troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken.”
There were further consistencies between officers and management meaning the witness was directed to discontinue his evidence and to return when he had reflected and was in a position to offer clarification. Despite this opportunity, the coroner recorded he had "heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances.
The supervising officer involved in the decision to close Mark’s ACCT on the morning of July 2023, gave evidence that there was no likelihood Mark would commit further acts of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents, and the officer did not consult a supervising officer as required by prison service instructions detailing ACCT procedures.’’
He continued "It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances”.
Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and or the coroner.
He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added: “I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.”
When it was pointed out to him that that was not supported by either of the witnesses involved, who were both very clear that there had been no consultation, he apologised and suggested he had misunderstood the evidence.
The coroner continued to record he was "troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken."
The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death. Mark was housed on House Block 3 North or ‘HB3’. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period.
The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3 South only. Every other prison witness asked about this agreed that there should be an officer covering both the North and South side of HB3 over the lunch period.
The Coroner was, with good reason “curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none.”
The matters of concern recorded in the PFD report were as follows:
Firstly, that, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby.
Significantly, that there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody.
It is unusual for a Coroner to refer to a lack of both reflection and candour in relation to evidence given at an inquest.
Mark’s family were represented by Karen Boyle of Park Lane Plowden Chambers instructed by Jenny Croston of Ison Harrison solicitors.
Jenny Croston, on behalf of the family, said:
“Had it not been for the advice of Coroner to contact INQUEST and seek legal representation and an extremely thorough coroner, it may have been that some of the the failures identified in Mark’s death may not have come to light.
To prevent future deaths we need proper scrutiny, transparency and accountability when investigating deaths. This starts with a duty of candour of prisons and their staff. Anything less than this, is an insult to families left behind and other prisoners reliant on the prison for their health and safety.”
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
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This is a media release by Ison Harrison, reshared by INQUEST
Before HM Area Coroner Michael Wall
Nottinghamshire Coroner’s Court
Inquest heard 7 – 15 October 2024
Prevention of Future Deaths report 25 October 2024
Following the Inquest into the death of Mark Beresford, HMAC Michael Wall delivered a scathing Prevention of Future Deaths report (PFD) to HMP Ranby. Of note he recorded that on two occasions, evidence given by a member of senior management was “incorrect and liable to mislead the jury and the coroner.”
Mark died on 7 July 2023 by self-inflicted means. The jury recorded that his death was by misadventure, but with with a damming narrative conclusion that identified several causative failings by both HMP Ranby and Nottingham Healthcare Trust.
Evidence was heard from senior management, Head of Operations at HMP Ranby, in relation to changes to the systems, policies and training after failings previously identified in the Prisons and Probation Ombudsman’s (PPO) Report following Mark’s death.
Evidence from same witness contradicted evidence previously given by staff from HMP Ranby involved in the circumstances surrounding Mr Beresford’s death.
The Coroner was “troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken.”
There were further consistencies between officers and management meaning the witness was directed to discontinue his evidence and to return when he had reflected and was in a position to offer clarification. Despite this opportunity, the coroner recorded he had "heard evidence that the prison authorities have already taken important steps, which I am satisfied address many of the concerns arising from Mark’s death. I am concerned however, that despite very strong evidence to the contrary, they maintained the risk assessments conducted on 2 and 3 July were reasonable in all the circumstances.
The supervising officer involved in the decision to close Mark’s ACCT on the morning of July 2023, gave evidence that there was no likelihood Mark would commit further acts of self-harm. While the inexperienced officer who later reopened the ACCT set Mark’s observations at one no more than two hours apart, relying in part on the fact that that is what they had been set at when the ACCT had been reopened the previous day. However, there had since been two significant risk incidents, and the officer did not consult a supervising officer as required by prison service instructions detailing ACCT procedures.’’
He continued "It is difficult to understand the prison’s position that these assessments were reasonable in all the circumstances”.
Furthermore, on two occasions, the Head of Operations gave evidence that was incorrect and liable to mislead the jury and or the coroner.
He gave evidence confirming the requirement for a person raising a concern under the ACCT process to consult with a supervising officer in respect of observation levels. He then added: “I firmly believe that the supervising officers who gave evidence earlier this week, whether they recall it or not, would naturally have had that conversation, out of being inquisitive, that would be my own personal view point but in terms of the prison stance, that’s what the policy says.”
When it was pointed out to him that that was not supported by either of the witnesses involved, who were both very clear that there had been no consultation, he apologised and suggested he had misunderstood the evidence.
The coroner continued to record he was "troubled by the fact that the Head of Operations, instead of reflecting on the significance of that evidence in terms of learning lessons from Mark’s death, suggested to the jury that these witnesses must have been mistaken."
The second occasion concerned the issue of cell bell cover on the day of the event that caused Mark’s death. Mark was housed on House Block 3 North or ‘HB3’. The Head of Operations gave evidence that it is normal for both HB3 North and HB3 South to have a single officer detailed to deal with cell bells over the lunch period.
The officer on duty on 3 July was however very clear in his evidence that he was detailed to cover HB3 South only. Every other prison witness asked about this agreed that there should be an officer covering both the North and South side of HB3 over the lunch period.
The Coroner was, with good reason “curious and concerned as to how a member of the prison’s leadership team could have made such an error, I later recalled and asked the Head of Operations for an explanation. He could provide none.”
The matters of concern recorded in the PFD report were as follows:
Firstly, that, notwithstanding steps since taken to improve work around ACCT processes and risk assessments, there remains an issue with understanding and assessing risk, which extends up to the leadership team at HMP Ranby.
Significantly, that there was a failure by the prison authorities to act with due reflection and candour during the inquest which, if unaddressed, will impede their ability to fully learn the lessons from deaths in custody.
It is unusual for a Coroner to refer to a lack of both reflection and candour in relation to evidence given at an inquest.
Mark’s family were represented by Karen Boyle of Park Lane Plowden Chambers instructed by Jenny Croston of Ison Harrison solicitors.
Jenny Croston, on behalf of the family, said:
“Had it not been for the advice of Coroner to contact INQUEST and seek legal representation and an extremely thorough coroner, it may have been that some of the the failures identified in Mark’s death may not have come to light.
To prevent future deaths we need proper scrutiny, transparency and accountability when investigating deaths. This starts with a duty of candour of prisons and their staff. Anything less than this, is an insult to families left behind and other prisoners reliant on the prison for their health and safety.”
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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