Michael BERRY · Prevention of Future Deaths report

On 17 March 2017 I 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:

I a Global hypoxic brain injury
I b Hanging
II Depression

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. A CT scan of his head was reported as normal. Sedation was stopped on 14 March 2017 but apart from breathing spontaneously, Michael showed no further signs of any meaningful neurological recovery. The opinion of the Neurologist was that he had sustained an hypoxic brain injury and the prognosis was very poor. Accordingly, life-sustaining treatment was withdrawn on 16 March 2017 and he died very shortly afterwards.

(1) Michael was in Healthcare Cell number 1 which throughout the Inquest was described variously as a “Reduced Risk Cell” or “Safer Cell”. It appears that in fact it is not a 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.