John Brandon Betteridge · Prevention of Future Deaths report

On 02.06.2015 I commenced an investigation into the death of John Brandon Betteridge, 43 years. The investigation concluded at the end of the inquest on28.06.2016. The conclusion of the inquest Suicide including a medical cause of death of 1a) Pressure on the Neck due to 1b) Hanging. The jury also concluded that the fact that the deceased did not have his prescription medication during his time of imprisonment during his time at HMP Durham possibly contributed more than minimally to his death. The jury concluded that the deceased should have been subject to an open ACCT at the time of his death. The jury also concluded that the fact that the deceased was not on an open ACCT at the time of his death probably contributed more than minimally to his death.

The deceased was remanded to HMP Durham on Friday 22nd May 2015. At an initial health screening it was recorded that he had a history of drug use and that he was taking prescribed medication for depression and anxiety but did not have any medication with him. He had self-harmed a long time previously but it was said had no current thoughts of suicide. He tested positive for the use of opiates. He was told that he would not be able to receive any prescribed medication until the prison GP could check the situation with his community GP which would not be until the following Tuesday as this was a bank holiday weekend. On the night of 23/24th May the deceased self-harmed. An ACCT was opened. Some 9 hours after the ACCT was opened the ACCT was closed. Healthcare staff were not present at the ACCT closure. The jury found that the deceased hung himself as an act of suicide on the night of Monday 25th May and was found dead at roll call in his cell at 4.55 am on the morning of Tuesday 26th May.

(1) A member of the Healthcare staff indicated that at the time of the death, though she was working in the prison, she had not received any ACCT training. I was told that ACCT training is now part of Healthcare staff induction training. A prison GP with 11 years’ experience of working in prisons stated that he had never received ACCT training though he had opened ACCTs. A Senior Officer who chaired the first review of the ACCT at which the ACCT was closed) believed it was good practice but did not know it was mandatory that healthcare staff should be present at such a review. The inquest has shown that notwithstanding that the ACCT process has been in existence for a number of years, some staff were working without having received any training and some either not had sufficient training or had forgotten it or were not applying it with the result that mandatory provisions in the ACCT process were not being adhered to. The inquest has indicated a clear training need.