Prisoner found hanged after two days in jail had told staff he heard voices urging him to kill himself

A prisoner who took his own life after less than two days in jail should have undergone an urgent mental health assessment before he died, an ombudsman has said.

Michael Berry, 24, was found hanged at HMP Bedford after telling staff he heard voices urging him to kill himself.

The Prisons and Probation Ombudsman, which investigated his death, found that information sent from court about his mental health “was not processed effectively”.

It said: “In addition, Mr Berry’s assertion that he was hearing voices telling him to kill himself should have prompted an urgent mental health assessment and a referral to a GP to consider prescribing antipsychotic medication as a matter of urgency.”

The ombudsman said there remained “significant issues” with the jail’s mental health service, which inspectors said last month was “inadequate in terms of its resources and coverage”.

Mr Berry was remanded in custody on 8 March last year after being charged with 22 offences including violence, kidnap and sexual assault of a man.

He had a history of drug and alcohol abuse and had twice been admitted to a mental health hospital following earlier suicide attempts.

A court nurse had asked Bedford prison’s mental health team to assess the risk of Mr Berry harming himself but the jail “had no record of receiving this email”, the ombudsman's report said.

A prison reception officer assessed Mr Berry without access to documents about his mental health and offending history. He was deemed to be high risk as he seemed “fragile” and was in withdrawal from heroin and crack cocaine, prompting staff to increase suicide and self-harm observation visits to five an hour.

The following day prison staff held a case review but healthcare workers were not invited, despite Mr Berry saying he heard voices telling him to kill himself. The ombudsman called this “disappointing” and said Mr Berry did not receive the level of care he would have got in the community.

Mr Berry was found hanged on 10 March. He was taken to hospital, where he died six days later.

He was the eighth prisoner to take his own life at Bedford since 2013.

In six of the resulting investigations, the ombudsman found staff operated suicide and self-harm prevention procedures ineffectively and recommendations were made to improve the assessment, care in custody and teamwork (ACCT) process. Four of the investigations identified failings in the mental health support offered to prisoners.

The ombudsman said Mr Berry’s death showed warnings had not been properly heeded.

Acting ombudsman Elizabeth Moody said: “Mental health care has been an issue in some of our recent investigations at Bedford and it is very disappointing to find that significant issues remain in the delivery of this service.”

A prison service spokeswoman said: “This is a tragic case and our thoughts remain with Mr Berry’s family and friends.

“We accepted all the recommendations from the Prisons and Probation Ombudsman and the prison has since made a number of improvements to the work it does to prevent suicide and self-harm.

“We are rolling out the key worker scheme ensuring that each prisoner has dedicated support from a prison officer and we have also funded the Samaritans helpline for a further three years.”

There have been no deaths at HMP Bedford in 2018.

Last month the prison watchdog has issued an official warning to the government about the jail, which it said was “on a path of seemingly inexorable decline”.

The Independent Monitoring Board described the prison a “dungeon” with infestations of rats and cockroaches, “disgusting” amounts of litter, and rising levels of violence.