Source · Prevention of Future Deaths
Ezra Tamiem
Ref: 2022-0220
Date: 19 Jul 2022
Coroner: Sean Cummings
Area: Bedfordshire and Luton
Responses identified: 0 / 2
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A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.
Date
19 Jul 2022
56-day deadline
13 Sep 2022
Responses identified
0 of 2
Coroner's concerns
A ligature point in a healthcare wing cell, not designed as a "safer cell," was used by the deceased and remains an unaddressed risk without plans for remedy.
View full coroner's concerns
Mr Tamiem was housed in a cell on the healthcare wing.
Head of Safety at HMP Bedford told the court that was for both security gave evidence that this device was in operation throughout the prison except in refurbished cells and except in the “safer cell”. The safer cell did not have this ligature point. Safer cells are cells with injury and ligature points designed out.
hanged himself and died as a result.
told the court there were no plans to remedy this and so the risk remains.
Head of Safety at HMP Bedford told the court that was for both security gave evidence that this device was in operation throughout the prison except in refurbished cells and except in the “safer cell”. The safer cell did not have this ligature point. Safer cells are cells with injury and ligature points designed out.
hanged himself and died as a result.
told the court there were no plans to remedy this and so the risk remains.
Report sections
Investigation and inquest
On 04 August 2020 I commenced an investigation into the death of Ezra Mathew TAMIEM aged 39. The investigation concluded at the end of the inquest on 16 December 2021. The conclusion of the inquest was that: On the 4th May 2020 Mr Ezra Tamiem was detained at HMP Bedford after stabbing his wife. On the 15th July 2020 Mr Tamiem was found in cell 3 in the healthcare wing of the prison at 0754 am hanging from a ligature he made. At 0806am he was confirmed to be deceased by the attending paramedics. The jury believes that with the evidence it has been presented that Mr Tamiem intended to take his life. We the jury believe that the authorities at HMP Bedford were aware of the risk of suicide. On the night of his death Mr Tamiem was to have four observations performed at random intervals. Of the 5 observations recorded only 2 were actually performed. Overall there was a serious failure of the observation procedure resulting in Mr Tamiem's death occurring between 21:11 and 07:54.
Circumstances of the death
Mr Ezra Mathew Tamiem was detained at HMP Bedford on the 4th May 2020 after being remanded following the stabbing of his wife. Because of concerns about his mental state and his risk of suicide, he was held in the healthcare wing. On the 15th July 2020 he was found in his cell
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Report details
- Reference
- 2022-0220
- Date of report
- 19 July 2022
- Coroner
- Sean Cummings
- Coroner area
- Bedfordshire and Luton
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Sep 2022.
Sent to
- HMP Bedford
- HMPPS