Daniel Beckford · Prevention of Future Deaths report

The inquest was opened on 13 July 2021 and concluded at the end of the inquest on 25 April 2024. The conclusion of the jury was a narrative conclusion: “suicide. Based on the evidence, the following possibly made a material contribution to his death; failure to comply with the prison service instruction to facilitate a phone call within the first 24 hours; insufficient support to secure a PIN.”

Daniel Beckford was detained at HMP Wandsworth. He died on 23 June 2023 aged 39 years. His death was confirmed at St George’s Hospital, Tooting Road, London.

The family requested the deceased is referred to as Daniel. I will reflect this in this report.

On 14 June 2021, Daniel was remanded to HMP Wandsworth. He had a history of substance misuse, depression and self-harm, which was known. On 16 June 2021 Daniel took an overdose of his prescribed antibiotic medication. On 17 June 2021, he was found hanging in his cell. At the time of his death, Daniel was being monitored via Assessment, Care in Custody and Teamwork (ACCT). He was transferred via LAS to St George’s Hospital and admitted to the General Intensive Care Unit (GICU). He was declared deceased on 23 June 2021. The medical cause of death was:

1a. Hypoxic ischemic brain injury;
1b. Asphyxia;
1c. Ligature compression of the neck; and
II Coronary artery atheroma

The jury’s findings recorded in the Record of Inquest included that there was “insufficient, regular Basic Life Support training, which resulted in Daniel being placed in the recovery position before CPR (chest compressions) commenced.”

(1) The provision and content of first aid training. The evidence of witnesses revealed an absence of clarity in the first aid training to prison officers on the use of rescue breaths during resuscitation attempts, as per current advice from the Resuscitation Council UK.