Ezra Mathew TAMIEM · Prevention of Future Deaths report

On 04 August 2020 I commenced an investigation into the death of Ezra Mathew TAMIEM aged 39. The investigation concluded at the end of the inquest on 16 December 2021. The conclusion of the inquest was that:

On the 4th May 2020 Mr Ezra Tamiem was detained at HMP Bedford after stabbing his wife. On the 15th July 2020 Mr Tamiem was found in cell 3 in the healthcare wing of the prison at 0754 am hanging from a ligature he made. At 0806am he was confirmed to be deceased by the attending paramedics. The jury believes that with the evidence it has been presented that Mr Tamiem intended to take his own life. We the jury believe that the authorities at HMP Bedford were aware of the risk of suicide. On the night of his death Mr Tamiem was to have four observations performed at random intervals. Of the 5 observations recorded only 2 were actually performed. Overall there was a serious failure of the observation procedure resulting in Mr Tamiem's death occurring between 21:11 and 07:54.

Mr Ezra Mathew Tamiem was detained at HMP Bedford on the 4th May 2020 after being remanded following the stabbing of his wife. Because of concerns about his mental state and his risk of suicide, he was held in the healthcare wing. On the 15th July 2020 he was found in his cell
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Mr Tamiem was housed in a cell on the healthcare wing. ████████ Head
of Safety at HMP Bedford told the court that was for both security ████████
████████ gave evidence that this device was in operation throughout the prison except in the refurbished cells and except in the “safer cell”. The safer cell did not have this ligature point. Safer cells are cells with injury and ligature points designed out.
████████ hanged himself
and died as a result.
████████ told the court that there were no plans to remedy this and so the risk remains.