Source · Prevention of Future Deaths
Michael Berry
Ref: 2018-0157
Date: 22 May 2018
Coroner: Ian Pears
Area: Bedfordshire & Luton
Responses identified: 0 / 1
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A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.
Date
22 May 2018
56-day deadline
2 Sep 2018 est.
Responses identified
0 of 1
Coroner's concerns
A "reduced risk" healthcare cell contained a clear ligature point, an inwardly opening window, indicating a design flaw that could be easily avoided.
View full coroner's concerns
(1) Michael was in Healthcare Cell number which throughout the Inquest was described variously as 'Reduced Risk Cell" or "Safer Cell" . It appears that in fact it is not reduced risk cell but more a 'Half Way House" in that the furniture is fixed to the floor. In the cell, however there was a very obvious ligature point that could be avoided, namely the window, which opens inwardly: On the face of it there would appear to be many design solutions that would overcome the need for an opening window that provides such an obvious ligature point:
Report sections
Investigation and inquest
On 17 March 2017 commenced an Investigation into the death of Michael BERRY, aged 34 years. The Investigation concluded at the end of the Inquest on 16 May 2018. The Conclusion of the Inquest was that Michael deliberately chose to suspend himself but the evidence did not fully explain whether or not he intended the outcome to be fatal. The medical cause of death was: Global hypoxic brain injury Hanging Depression
Circumstances of the death
The Deceased was found hanging from a sheet in the Medical Wing of Bedford Prison on 10 March 2017 . When found, he was unresponsive with no palpable pulse and his pupils were unreactive. He received basic life support from the prison staff who achieved return of spontaneous circulation. He was intubated at the scene by the Helicopter Emergency Medical Services Team. Following this he was transferred to Bedford Hospital and admitted to the Critical Care Unit where he remained intubated and ventilated.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action_
Similar PFD reports
Report details
- Reference
- 2018-0157
- Date of report
- 22 May 2018
- Coroner
- Ian Pears
- Coroner area
- Bedfordshire & Luton
Responses identified
Responses identified
0 of 1
1 response not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Sep 2018 (estimated).
Sent to
- HM Prison Bedford