Mark Beresford

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Mark Beresford,
a prisoner at HMP Ranby,
on 7 July 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, 2024
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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 focussed, evidenced and viable. This is especially the case
if there is evidence of systemic failure.
Mr Mark Beresford was found hanging in his cell at HMP Ranby on 3 July 2023. He was
resuscitated, but died in hospital on 7 July, never having regained consciousness. He
was 39 years old. I offer my condolences to Mr Beresford’s family and friends.
Mr Beresford was subject to suicide and self-harm monitoring (known as ACCT) for
some of the time he was in prison. He said he tied ligatures as a means of relieving
stress, although he told staff he did not want to die.
There were occasions when Mr Beresford’s risk to himself had potentially increased but
staff did not adequately assess or manage this. Staff closed Mr Beresford’s ACCT on 3
July, when it would have been prudent to leave it open. The next day, staff reopened
the ACCT at 12.15pm but failed to complete his immediate action plan within specified
timeframes. When Mr Beresford rang his cell bell at 12.53pm, the bell went unanswered
as there was no lunchtime patrol officer on the wing. Staff found him hanging at 1.26pm.
We shall never know Mr Beresford’s intentions when he began to hang himself, but his
history was to use ligatures as a means to relieve stress and perhaps as a signal to staff
that he needed help. When he rang his cell bell that afternoon, he would have expected
someone to respond within a brief time but tragically no-one responded.
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 July 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 15
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Summary
Events
1. On 24 February 2023, Mr Mark Beresford was remanded to HMP Nottingham
charged with affray and being in possession of an offensive weapon in a public
place. He was later sentenced to 12 months in prison. He was due to be released
on 25 August.
2. On 6 March, Mr Beresford told staff that he had swallowed three razor blades
following an altercation with his cellmate. Staff started Prison Service suicide and
self-harm monitoring procedures (known as ACCT). Mr Beresford moved to a
different wing.
3. Over the following weeks, Mr Beresford continued to speak about his fear of his
ex-cellmate and also said that other prisoners were talking about him and that he
was hearing voices. The ACCT was still open when Mr Beresford moved to HMP
Ranby on 11 April,
4. Mr Beresford gradually settled at Ranby although he continued to be fearful of his
ex-cellmate and at times placed ligatures around his neck. He said that he did
this as a way to relieve stress.
5. Mr Beresford’s ACCT had been closed for several weeks when he told an officer on
2 July that he wanted to hang himself. The officer re-opened the ACCT. Soon after,
Mr Beresford was seen on the landing with a ligature draped around his neck.
6. The ACCT was closed at a review at 9.15am on 3 July but was re-opened at
12.15pm when Mr Beresford was again found with a ligature around his neck.
7. The wing supervising officer (SO) should have arranged for Mr Beresford to be
seen within an hour for completion of an immediate action plan, but he thought that
other staff were making those arrangements. As no immediate action plan was
completed, no observations were set for Mr Beresford.
8. At the time Mr Beresford’s ACCT was being re-opened, officers left the Houseblock
to take their lunchbreak. Due to administrative errors, Houseblock 3 North, where
Mr Beresford was located, had no lunchtime patrol officer.
9. Mr Beresford rang his cell bell at 12.53pm, but it remained unanswered.
10. Following lunch, officers began to unlock prisoners for work. A prisoner found Mr
Beresford hanging in his cell at 1.26pm. Officers radioed a medical emergency
code, went into the cell, cut the ligature and started cardiopulmonary resuscitation
(CPR).
11. Paramedics arrived at 1.41pm and established a pulse. Mr Beresford was taken to
hospital and placed in intensive care. He died in hospital on 7 July.
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Findings
12. Mr Beresford was sometimes supported by the ACCT process. However, staff did
not always adequately assess or act on his potentially increasing risk to himself. It
would also have been prudent to have kept Mr Beresford’s ACCT open at the
review on the morning of 3 July.
13. The wing SO should have ensured that Mr Beresford was seen for completion of an
immediate action plan over lunchtime on 3 July.
14. Houseblock 3 North should not have been left without a lunchtime patrol officer at
the time that Mr Beresford hanged himself.
Recommendations
• The Governor should ensure that ACCT reviews are held whenever an event
occurs that could mean a prisoner is at increased risk and improve the quality
assurance process that confirms this learning has been embedded.
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The Investigation Process
15. HMPPS notified us of Mr Beresford’s death on 8 July 2023. The investigator
issued notices to staff and prisoners at HMP Ranby informing them of the
investigation and asking anyone with relevant information to contact him. One
prisoner responded.
16. The investigator obtained copies of relevant extracts from Mr Beresford’s prison
and medical records.
17. The investigator interviewed seven members of staff and one prisoner at Ranby
in September 2023. He interviewed a further member of staff in September by
video-link. He interviewed four further members of staff at Ranby in January and
February 2024 and another member of staff by video-link in February 2024.
18. NHS England commissioned a clinical reviewer to review Mr Beresford’s clinical
care at the prison. The investigator and clinical reviewer conducted joint
interviews with clinical staff.
19. We informed HM Coroner for Nottingham City and Nottinghamshire of the
investigation. She gave us the results of the post-mortem examination. We have
sent her a copy of this report.
20. The Ombudsman’s office contacted Mr Beresford’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Beresford’s mother asked:
• Why had it taken 90 minutes for staff to respond when her son pressed his
cell bell on 3 July? She did not believe that her son wanted to take his life;
she said pressing the cell bell was a cry for help.
• Why were items left in her son’s cell which he could potentially use to kill
himself?
• Why was her son not sent to a mental health unit?
21. We have answered these questions either within this report or in separate
correspondence.
22. We shared the initial report with Mr Beresford’s mother and with HM Prison and
Probation Service (HMPPS). Mr Beresford’s mother did not make any comments.
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Ranby
23. HMP Ranby is a medium risk training and resettlement prison in
Nottinghamshire. Nottinghamshire Healthcare NHS Foundation Trust provides
primary and mental health services.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Ranby was in March and April 2022.
Inspectors reported that levels of self-harm at Ranby were much lower than in
other similar category C prisons. They noted that there had been an effective
focus on improving delivery of the ACCT process, including advice and feedback
to staff through three-layer managerial checking. Inspectors noted that there was
a named coordinator for each ACCT who conducted all reviews if possible. In
addition, a member of the mental health team always attended initial case
reviews.
25. Inspectors found that the keyworker scheme was operating to an extent in that
most prisoners knew their named officer, but recorded interactions were often
brief and prisoners did not generally find them helpful. Inspectors noted that
response times to cell bells remained a concern and only 17% of prisoners said
that cell bells were normally answered within the five-minute target time.
26. Inspectors noted that a skilled and experienced mental health team provided a
range of support to prisoners and worked to the ‘stepped-care’ model to identify
prisoners’ needs (the ‘stepped-care’ model aims to deliver the most effective yet
least resource intensive treatment first).
Independent Monitoring Board
27. 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 March 2023, the IMB reported
that Ranby ran a generally courteous and respectful regime and in the main
staff/prisoner relationships were generally good. The IMB also considered that
Ranby was a safe prison.
Previous deaths at HMP Ranby
28. Mr Beresford was the sixth prisoner to die at Ranby since January 2020. Of the
previous deaths, two were self-inflicted, two were from natural causes and one
was from an overdose of stolen medication.
29. In our investigation into the death of a prisoner at Ranby in December 2021, we
found several deficiencies in the ACCT process, including that an ACCT was not
opened when the prisoner said that he was having suicidal thoughts and an
ACCT that was opened later was closed prematurely.
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Assessment, Care in Custody and Teamwork
30. Assessment, Care in Custody and Teamwork (ACCT) is the care planning
system the Prison Service uses for supporting and monitoring prisoners
assessed as at risk of suicide and self-harm. The purpose of the ACCT process
is to try to determine the level of risk posed, the steps that might be taken to
reduce this and the extent to which staff need to monitor and supervise the
prisoner. Levels of supervision and interactions are set according to the
perceived risk of harm. There should be regular multidisciplinary case reviews
involving the prisoner. Checks made on prisoners should be at irregular intervals
to prevent the prisoner anticipating when they will occur. Part of the ACCT
process involves assessing immediate needs and drawing up a care plan to
identify the prisoner’s most urgent issues and how they will be met. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
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Key Events
HMP Nottingham
31. On 24 February 2023, Mr Mark Beresford was remanded to HMP Nottingham
charged with affray and being in possession of an offensive weapon in a public
place. He was later sentenced to 12 months in prison and was due to be
released on 25 August 2023. It was not his first time in prison.
32. At a reception health screen on arrival at Nottingham, Mr Beresford said that he
was feeling okay, and he had no thoughts of suicide or self-harm.
33. On 6 March, staff started Prison Service suicide and self-harm monitoring
procedures (known as ACCT) after Mr Beresford said that he had swallowed
three razor blades. At an ACCT review that afternoon, Mr Beresford was noted to
be paranoid, anxious and agitated. He said that he felt unsafe in his current cell
due to an altercation with his cellmate. He also said that he thought other
prisoners on the wing believed that he was racist. Mr Beresford asked to move to
the segregation unit. Immediately after the ACCT review, Mr Beresford climbed
under the fourth landing netting. Staff moved Mr Beresford to a new cell on a
different wing.
34. On 7 March, a nurse noted that Mr Beresford had previously been prescribed
antidepressants in the community. He named three medicines he had been
prescribed in the past but said that he had not found any of them very helpful.
The following day, a doctor prescribed Mr Beresford sertraline (an
antidepressant).
35. Over the following weeks, Mr Beresford made further comments about fearing his
ex-cellmate, that other prisoners were talking about him and that he was hearing
voices. He said that he preferred to be alone or in small groups. Mr Beresford
isolated himself from other prisoners and, for a period of time, officers took his
meals to his cell. On a number of occasions, Mr Beresford rang his cell bell and
when staff responded they found him with a ligature around his neck. Mr
Beresford generally used bedding or clothing as ligatures. On one occasion, he
pressed his cell bell and then pushed a note under his door to say that he
believed he would be better off dead.
36. Mr Beresford was also subject to a Challenge Support Intervention Plan (CSIP –
used to support those who might be at risk from or a risk towards other
prisoners). This noted that he engaged well with his key worker and mental
health staff during ACCT reviews and completed in-cell education packs to keep
him occupied.
37. Staff closed Mr Beresford’s ACCT on 20 March but re-opened it three days later.
Mr Beresford’s ACCT observations were generally set at around one an hour to
one every two hours, although there were times when his observations were
more frequent than that, including from 14 March to 15 March when he was
under constant supervision.
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38. On 29 March, staff discussed Mr Beresford at a mental health team meeting and
referred him to the psychiatrist. (When Mr Beresford transferred to Ranby, mental
health staff considered that he did not meet the threshold for referral to a
psychiatrist.)
39. On 4 April, during a CSIP review, staff noted that Mr Beresford continued to self-
isolate and asked to transfer to another prison. Staff arranged for him to move to
HMP Ranby. On the morning of 11 April, Mr Beresford had an ACCT review ahead
of his transfer that day. Mr Beresford said that he was feeling positive as he had
been in Ranby in the past and he had a good relationship with the staff there. He
also said that he had a good relationship with his mother and partner, and he was
eager for his release from custody. Mr Beresford said that he had no thoughts of
suicide or self-harm, and staff maintained his observations at one an hour.
HMP Ranby
40. Mr Beresford arrived at Ranby in the early afternoon of 11 April and was seen by
a mental health nurse for a reception health screen. Mr Beresford said that he
had a history of cannabis misuse, suffered from depression and was struggling
with paranoia and hearing voices. The nurse noted that Mr Beresford was
prescribed sertraline, and this was continued.
41. At an ACCT review later that afternoon, Mr Beresford was noted to be visibly
nervous. He said that he was concerned about sharing a cell (as he had been in
a single cell at Nottingham), and he was advised to speak to induction staff about
this. He also said that he had heard that his ex-cellmate, who had been released
from prison, would stab him on his release. Staff kept Mr Beresford’s ACCT
observations at one an hour.
42. At around 9.13am on 12 April, staff radioed a medical emergency code blue (to
indicate a prisoner is unconscious or having breathing difficulties) when Mr
Beresford briefly lost consciousness after tightening a ligature around his neck. A
nurse noted that Mr Beresford had a small cut from falling and banging his head.
She also noted that by the time of his examination his clinical observations were
normal. Staff increased his observations to two an hour. At an ACCT review later
that day, chaired by a Supervising Officer (SO), Mr Beresford said that he used a
ligature as he was scared that he would have to share a cell and he had already
heard other prisoners using his name. He also explained that he used ligatures
for stress relief and not as suicide attempts. Staff increased Mr Beresford’s
observations to two an hour.
43. On 13 April, staff discussed Mr Beresford at the weekly safety intervention
meeting (SIM - where staff discuss prisoners who might need additional support
to that already being provided). An SO told the SIM about Mr Beresford’s fear
that he would have to share a cell and that he used ligatures as stress relief. The
SO said that he told Mr Beresford that he needed to find other, less dangerous
ways, to calm down. The SIM decided that Mr Beresford should continue to be
supported through his CSIP.
44. Mr Beresford pressed his cell bell at around midday and staff found him with a
plastic bin bag hanging loosely around his neck. He said that he was stressed as
he was still waiting for a phone and a television and that he needed these to
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keep him calm. At 3.10pm, Mr Beresford pressed his cell bell again and when
staff went to his cell he was unresponsive on his cell floor with a plastic bag
around his neck. An officer placed Mr Beresford in the recovery position and
radioed a medical emergency code blue. A nurse responded in a few minutes
and by the time she arrived Mr Beresford was responsive and sitting on a chair.
An SO chaired an immediate ACCT review and placed Mr Beresford under
constant supervision in a constant supervision cell. He had a television and
phone.
45. At an ACCT review on 14 April, Mr Beresford said that his reason for harming
himself the day before was because he had been told earlier in the day that he
would be getting a phone and a television, but the equipment did not arrive
quickly enough so he did not think he would get them. The SO who chaired the
review told Mr Beresford that using a ligature was a high-risk action and that he
was putting himself at significant risk of accidental harm. Mr Beresford said that
he understood the possibility of risk, but that was the method he used to deal
with his emotions. He stressed that he did not want to die. Staff reduced Mr
Beresford’s observations to two an hour.
46. Mr Beresford did not engage fully at his next ACCT review on 17 April and staff
kept his observations at two an hour.
47. On 20 April, staff discussed Mr Beresford at the mental health team multi-
disciplinary team meeting. They decided that he did not meet the threshold for
inclusion on the mental health caseload.
48. Mr Beresford’s next ACCT review was on 24 April. Mr Beresford spoke again
about his fear of retribution on release from prison. An SO (SO A) who chaired
the review, noted that Mr Beresford lacked confidence in coming out of his cell
and he spoke to him about steps to help him. Mr Beresford acknowledged that
his past cannabis use might have made him paranoid. He also said that he had
no present thoughts of suicide or self-harm. Staff reduced his ACCT observations
to one an hour.
49. The next day, SO A held a CSIP review with Mr Beresford. SO A noted that Mr
Beresford was gaining confidence and was not self-isolating anymore. He closed
the CSIP and noted Mr Beresford continued to be supported through an ACCT.
50. On 27 April, SO A went to see Mr Beresford, as staff said that he was upset. Mr
Beresford told SO A that everyone at Ranby knew he was “a grass” and that he
was going to start self-isolating again. SO A noted that after they spoke for a
while Mr Beresford agreed to co-operate with staff in trying to manage the
situation and that he would be allowed to lock himself in his cell if there were
times when he became overwhelmed.
51. SO A considered whether Mr Beresford needed to be subject to a CSIP again.
He recorded that Mr Beresford did not feel under threat from prisoners at Ranby
but was concerned that his cellmate from Nottingham would harm him, his
partner or mother on his release. SO A informed the police liaison officer and
concluded no CSIP was necessary at that time since Mr Beresford did not
currently feel under threat.
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52. At the early evening routine check on 29 April, Mr Beresford was seen sitting on
his bed with a jumper loosely around neck. Officers went into the cell and took
the jumper from him. Mr Beresford again spoke about his fear of retribution. An
SO noted that he managed to calm Mr Beresford and he removed some items
from the cell that could be used as ligatures. The SO also noted that Mr
Beresford’s actions presented no change to his level of risk. The SO (incorrectly)
believed that Mr Beresford was being observed twice an hour and noted that
observations should continue at that level.
53. At an ACCT review on 4 May, staff noted that Mr Beresford’s state of mind had
improved, and he was coming out of his cell to collect his meals. He said that he
had a good rapport with the wing staff and Houseblock 3 was the best place for
him at that time. He also said that he still needed the support of ACCT
observations due to his tendency to self-harm in reaction to stress rather than
working his way through his frustrations by other means. Staff reduced Mr
Beresford’s observations to one an hour. On 11 May, staff further reduced his
observations to one every three hours.
54. On 12 May, the SIM noted that Mr Beresford was receiving support through
ACCT and had contact with mental health staff as part of that. The SIM agreed
that Mr Beresford was no longer in crisis and could be removed from the SIM
workload.
55. At an ACCT review on 18 May chaired by SO A, Mr Beresford said that he had
heard that his ex-cellmate had been ‘scoping-out’ his address. Other than that
comment, Mr Beresford seemed well. SO A noted that all at the review agreed
that the ACCT would be considered for closure at the next review. In the
meantime, Mr Beresford would have two conversations a day with officers, but
there was no need for observations.
56. On the evening of 18 May, Mr Beresford told an officer that he would kill himself
at some point in the night but was waiting for telephone credit to be added at
midnight so he could tell his partner what he was going to do. The officer noted
the comment in Mr Beresford’s ACCT, but there is no record that he took any
action or reported the comment to the Orderly Officer, the senior officer on duty.
57. On 25 May, SO A held an ACCT review with Mr Beresford. A mental health nurse
was also at the review. Mr Beresford again spoke about his fear of reprisal from
his ex-cellmate, but also acknowledged that he “over-thought” matters and
accepted that his past cannabis use might have affected his thinking. SO A noted
that despite his anxiety, Mr Beresford was looking forward to his release and
being with his family again. SO A noted that all agreed that the ACCT could be
closed: the ACCT was then placed in ‘post-closure’, a seven-day period for staff
to assure themselves that the prisoner is coping and is not at risk.
58. On 1 June, an officer introduced himself to Mr Beresford as his keyworker and
explained that the role gave dedicated time to discuss his needs and any worries.
Mr Beresford said that he believed staff and other prisoners talked about him
“behind his back” so he was unsure who to trust. However, his only concern at
that time was understanding the prison release process. The officer noted that
since Mr Beresford’s ACCT had been closed, he had made major improvements
to how he was living on the wing and was socialising with other prisoners.
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59. On 3 June, SO A saw Mr Beresford for an ACCT post closure review. SO A
noted that Mr Beresford engaged throughout the review and raised no new
issues of concern. He noted that the ACCT was to remain closed.
60. On 23 June, a GP saw Mr Beresford as he had not collected his sertraline tablets
in the past few days. Mr Beresford said that he had been suffering cold and flu
symptoms and he thought the sertraline might make his symptoms worse. The
GP reassured him that that would not be the case and Mr Beresford said that he
would start collecting his medication again. (Mr Beresford was frequently non-
compliant with his medication giving various reasons including saying that
sometimes he was anxious about joining the medication queue and that
sometimes officers did not unlock him. Nurses reminded him to take more
responsibility, including that he should ring his cell bell if officers did not unlock
him for medication.)
61. On 30 June, the keywork officer had another keyworker meeting with Mr
Beresford. Mr Beresford again spoke about his fears of his ex-cellmate upon his
release, but he admitted that it was most likely a fear that he had built up in his
mind. The keywork officer noted that Mr Beresford’s confidence had improved
during his time on Houseblock 3, he was collecting his meals and medication and
regularly engaged with staff and other prisoners.
Events of 2 July
62. Mr Beresford rang his cell bell at 12.39pm on 2 July and told an officer that his
ACCT should not have been closed and that he wanted to hang himself. The
officer re-opened Mr Beresford’s ACCT.
63. At around 2.00pm, an SO (SO B) saw Mr Beresford to complete an immediate
action plan: a plan to keep him safe for the first 24 hours or until his first case
review. Mr Beresford said that he did not want to die, but he again spoke about
his fears of being attacked after his release. SO B agreed with Mr Beresford that
he would be observed at intervals of no more than two hours and that he would
have an ACCT review the following day.
64. At around 3.30pm, a prisoner told an officer that Mr Beresford was on the third
landing with a bedsheet draped around his neck. The officer went to see Mr
Beresford and asked him to take the bedsheet from his neck, which he did. The
officer asked Mr Beresford if he wanted to see somebody from the safer custody
team or healthcare, but he declined the offer. The officer told Mr Beresford not to
do anything stupid, but to speak to staff instead if he needed anything. The
officer said that he informed the wing SO about this incident, although the SO
said that he was not informed.
65. The investigator viewed CCTV footage for the afternoon of 2 July when prisoners
were free to mix on the wing from 2.00pm to 4.45pm. The investigator noted that
Mr Beresford spent the entire period out on association. He occasionally spoke a
few words to other prisoners, but generally spent his time walking alone around
the wing and sometimes leaning on the railing. There was no indication from his
body language to suggest that he had any fear of other prisoners.
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66. At around 5.20pm, an officer noted that Mr Beresford began crying after speaking
about what might happen to him or his mother after his release from prison.
67. The investigator listened to Mr Beresford’s telephone calls for 2 July. He
telephoned his mother in the morning and he telephoned his partner in the early
afternoon and again in the early evening. In all three calls he talked about his
fear of retribution from the ex-cellmate and that the family might have to move to
a new area. (Mr Beresford and his partner lived at his mother’s home.) During the
calls Mr Beresford’s mother and partner tried to reassure him including saying
that they would move home if necessary.
68. Mr Beresford’s ACCT contains no record of any ACCT checks between 5.00pm
and 10.00pm. However, the officer on duty on Houseblock 3 that night noted that
Mr Beresford had slept all night and that he had given no reason for concern.
Events of 3 July
69. At 9.15am on 3 July, SO A collected Mr Beresford from his cell for an ACCT
review. A nurse also attended, along with another mental health nurse who was
shadowing the nurse. SO A asked Mr Beresford why he had not been on
association when he collected him for the ACCT review. Mr Beresford again said
that it was fear of his ex-cellmate and that was why he sometimes did not come
out of his cell to collect his medication. Mr Beresford confirmed that he was well
supported by his mother and partner, and they had installed CCTV at the home.
His mother had also contacted the police for rapid response protection upon his
release. Mr Beresford said that he had no present thoughts of suicide or self-
harm and that he would seek support from staff if necessary.
70. The nurse told Mr Beresford that sertraline would help him with his anxiety and
Mr Beresford agreed he would start to collect his medication again. The nurse
noted that Mr Beresford recognised that he was not under threat at Ranby and
that other prisoners had helped him the day before when they saw him with a
ligature. The nurse wrote that Mr Beresford engaged well at the review and that
there were no signs of poor mental health.
71. SO A noted that all at the review agreed that the ACCT should be closed and
moved to post-closure.
72. The investigator asked SO A whether he thought about keeping the ACCT open
to see if Mr Beresford would start coming out of his cell again for association and
to collect his medication. SO A said that Mr Beresford said at the review that he
did not want to use ACCT as a crutch as he knew that support would not be there
for him on his impending release from prison. He also never said at any time that
he wanted to die, he just wanted help and a conversation. SO A said that if Mr
Beresford had still been anxious at the end of the review he would not have
closed the ACCT.
73. CCTV shows that Officer A went to Mr Beresford’s cell at 11:42am after he rang
his cell bell and again at 11:47am when he rang his cell bell once more. The
officer spent a few seconds talking to Mr Beresford each time and he then told
the keywork officer that Mr Beresford was being unusually aggressive towards
him and suggested that the keywork officer should speak to him as they had a
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better rapport. The keywork officer went to the cell at 12.06pm and, when he
looked into the cell, he saw Mr Beresford with a pillowcase around his neck
which he was tightening with both hands. Both officers went into the cell and Mr
Beresford agreed to take the pillowcase from his neck. He said though that he
was unsure whether he still wanted to be released as the problem with his ex-
cellmate would follow him home and put his mother at risk. The keywork officer
spent nine minutes in the cell speaking to Mr Beresford. He told him that he
would re-open the ACCT and he would see him again in the afternoon.
74. The keywork officer B told SO B and another SO (SO C) that he was going to re-
open the ACCT and he then started to complete the paperwork.
75. SO C telephoned a Custodial Manager (CM – CM A) , the officer in charge, to
report the routine count of all prisoners and, in line with policy, she also told her
that Mr Beresford’s ACCT had been re-opened. Once the keywork officer
completed the ACCT paperwork, he telephoned CM B, who was sharing an office
with CM A, to give the details of why he had re-opened the ACCT.
76. A trained member of staff of at least SO grade should have seen Mr Beresford
within the next hour to complete his immediate action plan, but this did not
happen. CM B told the investigator that the wing SO was responsible for making
those arrangements. As no action plan was completed, no observations were set
for Mr Beresford.
77. SO C finished her shift at 12.15pm and left the prison. At around the same time,
SO B left Houseblock 3 to take his lunch break. He told the investigator that he
had completed the daily staff detail for Houseblock 3, which he had done the
previous afternoon. He had gone through the published establishment detail
which contained the shift patterns and allocation detail for all of the staff at
Ranby. From that, he had entered the names of the officers on duty on
Houseblock 3 throughout the day, including which staff were due to work on
Houseblock 3 North (where Mr Beresford was located), and which staff were due
to work on Houseblock 3 South.
78. The investigator was shown a copy of the establishment detail which comprised
around 100 pages and was told that the only way for an SO to determine which
staff were allocated to his or her wing was to work through all of the pages to pick
out the names. From that information, the SO would then produce a single A4
page with the wing staffing detail for the day. During the lunch period,
Houseblock 3 should be staffed by two patrol officers: one officer for the North
side and one for the South. Staff completing the establishment detail for that day
failed to allocate an officer for lunchtime patrol on Houseblock 3 North. SO B told
the investigator that he had not noticed this omission when he produced the
specific staff detail for Houseblock 3. When he went for his break that day, he did
not realise that Houseblock 3 North was left unstaffed.
79. CCTV shows that the keywork officer left Mr Beresford’s cell at 12.15pm. At
12.53pm, Mr Beresford rang his cell bell. The only officer on duty at that time on
the Houseblock was Officer B, the lunchtime patrol officer for Houseblock 3
South. Officer C told the investigator about some of the duties he completed
during that lunch period, which included answering cell bells on both the South
and North sides of the Houseblock. He said that he did not hear Mr Beresford’s
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cell bell. The investigator visited Houseblock 3 and noted that cell bells were only
audible in certain areas and that it was entirely possible for an officer on the
South side to be unaware that a cell bell had been rung on the North side. Officer
C acknowledged that at some stage during that period he realised that the North
side was unstaffed. However, he did not take any action or alert the officer in
charge.
80. At around 1.20pm, officers had returned from their lunch breaks and began to
unlock prisoners on Houseblock 3 North for work. CCTV shows that at 1.26pm a
prisoner noticed that Mr Beresford’s cell bell light was on and when he looked
into the cell, he saw him hanging. The prisoner shouted to staff and Officer A
reached Mr Beresford’s cell in around 30 seconds. He looked into the cell, called
for further support, and went into the cell. Mr Beresford had looped a ligature
around the window frame and was hanging in a slumped position with only his
heels touching the floor. He lifted Mr Beresford’s body. Another officer arrived 15
seconds later and cut the ligature. The officers then lowered Mr Beresford to the
cell floor and started cardiopulmonary resuscitation (CPR). The keywork officer
reached the cell a few seconds later and he radioed a medical emergency code
blue. Staff in the control room immediately requested an ambulance.
81. A nurse was near Houseblock 3 when she heard the code blue and she arrived
at Mr Beresford’s cell at 1.29pm. She saw officers performing CPR and noted
that while Mr Beresford had a good colour, he also had vomit in his mouth and
nose. She tried to insert an airway device to give oxygen but there was too much
vomit. She tried to suction the vomit but was only able to remove a small amount.
She then used a different type of airway device and was able to maintain an
airway and give oxygen. Officers took turns in giving CPR while the nurse
continued giving oxygen. Mr Beresford was checked regularly with a defibrillator,
but it advised each time that no shock could be given, and that CPR should
continue.
82. Paramedics arrived at 1.41pm. They took charge of Mr Beresford’s care and
established a pulse. At 2.18pm, Mr Beresford was taken to hospital without
restraints.
83. Mr Beresford remained in intensive care until he died in the late evening of 7
July.
Contact with Mr Beresford’s family
84. At 3.15pm on 3 July, one of Ranby’s family liaison officers telephoned Mr
Beresford’s mother to tell her that her son had been taken to hospital and was in
a critical condition. Mr Beresford’s mother said that she had no transport, so
Ranby sent a prison vehicle to her home and took her to hospital where she
arrived at around 5.00pm. Mr Beresford’s mother and other family members were
with him when he died on 7 July. Ranby contributed to the cost of Mr Beresford’s
funeral in line with national instructions.
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Support for prisoners and staff
85. On the afternoon of 3 July, the Governor and Deputy Governor 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.
86. After Mr Beresford’s death, one of Ranby’s functional heads debriefed the
bedwatch officers who were with Mr Beresford when he died.
87. Ranby 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.
Post-mortem report
88. The pathologist gave Mr Beresford’s cause of death as hypoxic brain damage
(caused by a lack of oxygen) as a result of hanging. His toxicology report had no
significant findings.
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Findings
Management of Mr Beresford’s risk of suicide and self-harm
89. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of self-harm or suicide posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under ACCT procedures. PSI 64/2011
also states that any information that becomes available which may affect a
prisoner’s risk of harm to self must be recorded and shared, to inform proper
decision making.
90. Throughout his time at Ranby Mr Beresford remained highly anxious about a real
or perceived risk posed to him and his family from a prisoner with whom he had
shared a cell at Nottingham. As a result, there were times that Mr Beresford
would not come out of his cell. He had a habit of placing ligatures around his
neck to relieve his anxiety. There were at least two occasions before 3 July that
Mr Beresford briefly lost consciousness from tightened ligatures, but there is no
evidence to suggest that he intended to take his life on those occasions. It also
seems that sometimes Mr Beresford wanted to be seen with a ligature as that
signalled to staff that he needed help. Staff advised him of the dangerousness of
his actions and Mr Beresford said that he was aware of this, but it was his means
of relieving stress.
91. The investigator asked the Head of Safety if Mr Beresford should have had
enhanced ACCT case reviews (which are attended by more senior members of
staff and a wider range of participants). He said that certain prisoners are
deemed complex cases and will have a higher level of scrutiny. Prisoners who
fall into this category are those who are under constant supervision, prisoners
who have a mental disorder that might require transfer to a mental health unit
and those who engage in prolific self-harm. Mr Beresford therefore did not meet
the threshold. He had been referred to the SIM and discussed there twice before
senior staff were satisfied that Mr Beresford was receiving appropriate support.
92. The majority of Mr Beresford’s ACCT reviews at Ranby were multidisciplinary with
reasonably consistent case management by SO A and good attendance by mental
health nurses. Staff also tried to ensure that Mr Beresford understood how
dangerous tying ligatures was.
Assessment of escalated risk
93. On the evening of 18 May, Mr Beresford told an officer that he intended to kill
himself sometime that night but there is no record that the officer in charge was
informed. Staff should have held an urgent case review, reviewed Mr Beresford’s
level of risk and considered whether observations needed to be restarted (he was
subject to two conversations a day and no observations at the time).
94. It is also unclear whether the officer told the wing SO when he found Mr Beresford
with a ligature around his neck at 3.30pm on 2 July. A review of Mr Beresford’s risk
should have taken place and consideration given to increasing his observations.
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These were set at every two hours at the time which is arguably too low for
someone who has just been found with a ligature around their neck.
Missing ACCT observations
95. Mr Beresford’s ACCT contains no record of ACCT checks between 5.00pm and
10.00pm on 2 July. We note that this omission was identified during an early
learning review following Mr Beresford’s death.
Closure of ACCT
96. Staff closed Mr Beresford’s ACCT in the morning of 3 July. At that review, Mr
Beresford spoke again about his fears related to his previous cellmate and said that
he had not been coming out of his cell to collect his medication. Mr Beresford said
he was content for the ACCT to be closed that morning, recognising that support
through ACCT would not be available to him after his release from prison. However,
it is clear that Mr Beresford benefited from discussion with and reassurance from
staff about his safety. While we acknowledge that ACCT support would not have
followed Mr Beresford into the community, he would instead of course then had the
support of his mother and partner. We consider, on balance, that it would have
been prudent to have kept Mr Beresford’s ACCT open pending his approaching
release. Keeping the ACCT open would also have allowed staff to monitor Mr
Beresford’s promise to start coming out of his cell to collect his medication. This is
particularly in light of the fact that he had tied a ligature round his neck the previous
day.
Failure to complete an immediate action plan
97. When staff re-opened Mr Beresford’s ACCT at 12.15pm on 3 July, arrangements
should have been made for a trained member of staff of at least SO grade to see
him within an hour to complete an immediate action plan. It seems that SO B
believed that the officer in charge would be responsible for identifying a person to
complete the plan during the lunch period. However, CM B was clear that the
responsibility fell to SO B to complete the plan himself or identify a colleague to
complete it. In the absence of an immediate action plan, Mr Beresford was not
subject to ACCT observations over the lunchtime period.
Lunchtime patrol
98. When Ranby published its daily staffing detail for Houseblock 3 for 3 July, Officer B
was identified as the lunchtime patrol officer for Houseblock 3 South, but no officer
was identified as lunchtime patrol officer for Houseblock 3 North. When SO B went
through the lengthy overall prison detail to produce a specific daily detail for
Houseblock 3, he did not notice this omission. This meant that Houseblock 3 North
was left unpatrolled that lunchtime.
99. Records show that Mr Beresford rang his cell bell at 12.53pm but the call was not
answered. At 1.26pm, a prisoner found Mr Beresford hanging in his cell. We do not
know at what time Mr Beresford began to hang himself, however the fact that staff
were able to resuscitate him would suggest that he did not hang himself
immediately after ringing his cell bell and it seems likely that he would have
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expected staff to come to speak to him as had always happened previously. While
we cannot be certain about Mr Beresford’s intentions, it seems likely that his actions
that afternoon started as a means of stress relief and getting help from staff, not as
a determined effort to take his life.
Action taken since Mr Beresford’s death
100. The Head of Safety told the investigator that he was aware of a number of the
failures of care that had occurred in Mr Beresford’s case. These included SO B’s
failure to complete an immediate action plan on 3 July or notice that the staffing
detail did not identify an officer for lunchtime patrol on Mr Beresford’s Houseblock.
He said that SO B, who at the time was very new in post, had been subject to an
internal investigation, at which he acknowledged his omissions. The Head said that
the investigation resulted in SO B receiving targeted advice and guidance. In
addition, the Head said that the since Mr Beresford’s death, Ranby had introduced
a secondary check to identify any omissions in the staffing detail and all SOs have
been reminded about the need to check the detail when completing the specific
detail for their own wing.
101. The Head of Safety also recognised that during the ACCT quality assurance
process, staff occasionally identified ACCT observations that had been missed.
Wing managers then addressed any missed checks with staff concerned.
102. We are satisfied that most of the issues identified in the assessment and
management of Mr Beresford’s risk to himself have been addressed since his
death. However, we remain concerned that there were times when his potentially
escalating risk was not assessed nor was an urgent ACCT case review held. We
make the following recommendation:
The Governor should ensure that ACCT reviews are held whenever an event
occurs that could mean a prisoner is at increased risk and improve the quality
assurance process that confirms this learning has been embedded.
Clinical care
103. The clinical reviewer concluded that Mr Beresford’s care at Ranby was of a good
standard and equivalent to that which he could have expected to receive in the
community. She noted that he was assessed by the mental health team and
found not to reach the threshold for inclusion on the mental health team
caseload. She also noted that he continued to receive input from the mental
health team during ACCT reviews.
104. The clinical reviewer noted that there had been problems with the manual suction
machine during the emergency response on 3 July, but the prison has since
acquired an electronic suction machine. The clinical reviewer made no
recommendations.
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Good Practice
105. We consider it an example of good practice that Ranby sent a prison vehicle to
take Mr Beresford’s mother to hospital so she could be with her son with a
minimum of delay.
Governor to note
106. We note that Officer B recognised at some stage that there was no patrol officer
on Houseblock 3 North at lunchtime on 3 July. He should have informed the
officer in charge by radio. All staff should understand that they have a corporate
responsibility towards the safety and security of the prison. The Governor will
wish to ensure that all staff are aware of this responsibility.
Inquest
107. An inquest into Mr Beresford’s death concluded on 15 October 2024 that his
death was due to misadventure.
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