A prisoner who took his personal life after lower than two days in jail ought to have undergone an pressing psychological well being evaluation earlier than he died, an ombudsman has mentioned.

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

The Prisons and Probation Ombudsman, which investigated his loss of life, discovered that info despatched from court docket about his psychological well being “was not processed successfully”.

It mentioned: “As well as, Mr Berry’s assertion that he was listening to voices telling him to kill himself ought to have prompted an pressing psychological well being evaluation and a referral to a GP to think about prescribing antipsychotic remedy as a matter of urgency.”

The ombudsman mentioned there remained “vital points” with the jail’s psychological well being service, which inspectors mentioned final month was “insufficient by way of its sources and protection”.

Mr Berry was remanded in custody on eight March final 12 months after being charged with 22 offences together with violence, kidnap and sexual assault of a person.

He had a historical past of drug and alcohol abuse and had twice been admitted to a psychological well being hospital following earlier suicide makes an attempt.

A court docket nurse had requested Bedford jail’s psychological well being crew to evaluate the chance of Mr Berry harming himself however the jail “had no report of receiving this e-mail”, the ombudsman’s report mentioned.

A jail reception officer assessed Mr Berry with out entry to paperwork about his psychological well being and offending historical past. He was deemed to be excessive danger as he appeared “fragile” and was in withdrawal from heroin and crack cocaine, prompting workers to extend suicide and self-harm statement visits to 5 an hour.

The next day jail workers held a case evaluate however healthcare staff weren’t invited, regardless of Mr Berry saying he heard voices telling him to kill himself. The ombudsman known as this “disappointing” and mentioned Mr Berry didn’t obtain the degree of care he would have gotten locally.

Mr Berry was discovered hanged on 10 March. He was taken to hospital, the place he died six days later.

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

In six of the ensuing investigations, the ombudsman discovered workers operated suicide and self-harm prevention procedures ineffectively and suggestions have been made to enhance the evaluation, care in custody and teamwork (ACCT) course of. 4 of the investigations recognized failings within the psychological well being assist provided to prisoners.

The ombudsman mentioned Mr Berry’s loss of life confirmed warnings had not been correctly heeded.

Appearing ombudsman Elizabeth Moody mentioned: “Psychological well being care has been a difficulty in a few of our latest investigations at Bedford and it is extremely disappointing to search out that vital points stay within the supply of this service.”

A jail service spokeswoman mentioned: “This can be a tragic case and our ideas stay with Mr Berry’s household and pals.

“We accepted all of the suggestions from the Prisons and Probation Ombudsman and the jail has since made various enhancements to the work it does to stop suicide and self-harm.

“We’re rolling out the important thing employee scheme making certain that every prisoner has devoted assist from a jail officer and we’ve got additionally funded the Samaritans helpline for an additional three years.”

There have been no deaths at HMP Bedford in 2018.

Final month the jail watchdog has issued an official warning to the federal government concerning the jail, which it mentioned was “on a path of seemingly inexorable decline”.

The Unbiased Monitoring Board described the jail a “dungeon” with infestations of rats and cockroaches, “disgusting” quantities of litter, and rising ranges of violence.

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