Before HM Assistant Coroner for County Durham, Oliver Longstaff
7 October to 27 October 2020
 
The inquest into the death of Garry Beadle concluded yesterday that issues in record keeping and information sharing at HMP Durham possibly contributed to his death. Garry was 36 years old when he was found hanging in his cell and he died in hospital four days later on 11 February 2019. He was in custody on remand and had only been at the prison for six days. His death was found to be suicide.
 
HMP Durham has seen the highest number of self-inflicted deaths of any prison in England and Wales this past year. Since Garry’s death there have been a further seven self-inflicted deaths, four of whom were also men on remand. The most recent review of HMP Durham by prison inspectors in 2019 identified insufficient progress on reccomendations relating to the management of prisoners at risk of suicide.
 
The inquest heard that it was Garry’s first time in prison. He arrived at HMP Durham on 1 February 2019 with a suicide and self-harm warning form (known as SASH*). It recorded that Garry had attempted to hang himself and had taken an overdose in the last two weeks. He had told a Magistrate and his solicitor he would not last two days in prison. The form also recorded Garry’s repeated statements that he had mental ill health.
 
On reception at HMP Durham, a senior prison officer discussed the SASH form with Garry. Garry told the officer he felt so down he would attempt to take his life again, and that he missed his children “like crazy”. However, the officer did not fully record this, which he accepted at the inquest was a missed opportunity for information sharing. Garry was subsequently seen by a nurse for his initial health screening who, despite the information on the SASH form, recorded that Garry had not overdosed in the last twelve months. The jury heard this nurse had not received training on prison suicide and self-harm management (known as ACCT*) for five or six years, and had no training on SASH forms. The jury concluded that inconsistent training across prison service also possibly contributed to Garry’s death.
 
The jury were told Garry also had additional risk factors including being a remand prisoner, it being his first time in custody, his diagnosis of depression for which he received medication in the community, and a recent breakdown of a relationship. Despite this and the information available, Garry was not placed under ACCT monitoring procedures by the officer at reception or the nurse. Garry did not receive his anti-depressant medication until three days later.
 
An ACCT was opened by a mental health nurse later that day. Initially Garry was put on hourly observations. After the first ACCT review the following day, these were reduced to just six regular observations over each day and night, despite Garry reporting feeling overwhelmed. The jury heard that this is common amongst people who are in custody for the first time. His risk of self-harm and suicide was assessed to be low. A Custodial Manager reviewing the form for quality assurance later, on 4 February, changed the level of risk to ‘raised’.
 
On the afternoon of 3 February 2019, the jury heard that Garry had telephoned a close friend. The friend was extremely concerned and felt Garry was saying goodbye. Garry asked his friend to look after his children and said “I have everything I need now to do what I am going to do.” The friend contacted Northumbria Police about his concerns, who then spoke to the prison.
 
HMP Durham recorded the police contact in security intelligence records, which healthcare staff and most prison officers do not have access to. The information was not passed on to mental health staff or anyone involved in the ACCT reviews. Witnesses confirmed they would have expected a record of this call to appear on the ACCT document. One officer said, had it been recorded, they would have considered raising Garry’s risk to high.
 
A senior nurse manager at Tear Esk and Wear Valley NHS Foundation Trust, who provide mental health services in HMP Durham agreed that this was a missed opportunity for important information about Garry’s risk to himself to be shared. The Governor of HMP Durham told the jury that there is no evidence that the security intelligence record was passed to the Safer Custody department, or to a Governor to review, as it should have been.
 
On the morning of 7 February, a scheduled ACCT review took place, attended by a custodial manager and a mental health nurse. Based on Garry’s presentation, his level of risk of harm to himself was reduced from ‘raised’ to ‘low’. This was despite an incident the evening before where Garry had been distressed about a change in his cellmate, and was left as the single occupant in his cell. The custodial manager was still not aware of Garry’s phonecall to his friend, and accepted that as a result the risk assessment was inadequate. Had they known, they would have considered his risk to be high. Garry was found hanging in his cell at 2pm that day.
 
Garry was born in London, raised in Watford, and moved to Newcastle where he lived for 12 years. He had five children, one of whom tragically died at four weeks old. His family described Garry as being a loving and mischievous child, who was never happier when he had his football boots on. Garry was an important and influential member of his local football team Oxhey Jets, and a stand has been named in his honour.
 
Karen Beadle, Garry’s mother, said: "As Garry's mum, I truly feel many of us have lost a very special person. A joker, prankster, loved being with his friends and his passion for football never faltered, a talent he excelled in. After all the evidence from the inquest has come to light, it is crystal clear that Garry was overwhelmed, confused, emotional and that more attention should of been paid to the red flags that Garry was waving for help and support. We now know that fundamental errors were made in Garry's short time at HMP Durham.
 
We must do more to protect people in these positions, as I do not want any other families to go through what I have and am. I would like to take this opportunity in thanking my legal representatives Tara Mulcair and Stephen Clark for their exemplary professionalism throughout this inquest and for going above beyond throughout this time."
 
Jasmine Leng, Senior Caseworker at INQUEST, said: “All the warning signs were there, but Garry was fundamentally failed by those who owed him a duty of care. Durham prison has seen the highest number of self-inflicted deaths over the past ten years. Yet not enough was done to address the serious issues identified by the Inspectorate, Ombudsman and at previous inquests. Garry died as a result of this failure.
 
We simply cannot wait any longer for substantial and sustainable change in prisons. We must look beyond the use of prison and act upon what are clear solutions - tackling sentencing policy, reducing the prison population and redirecting resources to community, health and welfare services.”

Tara Mulcair, Solicitor at Birnberg Peirce who represented the family, said: “Garry’s death has highlighted, once again, the systemic failings in self-harm and suicide monitoring procedures at HMP Durham. There were failings and missed opportunities to share information relevant to risk on almost every single day of Garry’s short time in HMP Durham. It is vital that HMP Durham and the Ministry of Justice ensure that lessons are learned so that the failings in Garry’s case are not repeated in the future.”

ENDS

NOTES TO EDITORS

For further information and to note your interest, please contact INQUEST Communications Team 020 7263 1111 or email [email protected]. A photo of Garry is available here.
 
Please refer to the Samaritans Media Guidelines for reporting suicide and self-harm in using the content of this media release.

Garry’s mother Karen Beadle is represented by INQUEST Lawyers Group members Tara Mulcair of Birnberg Peirce and Stephen Clark of Garden Court Chambers. Karen is also supported by INQUEST caseworker Jasmine Leng.
 
Other Interested persons represented at the inquest are the Ministry of Justice, Tees Wear and Esk Valley NHS Foundation Trust (responsible for mental health services in HMP Durham), GEOAmey (responsible for security staff at Bedlington Magistrates Court), G4S, Spectrum (responsible for physical healthcare in HMP Durham).
 
*ACCT is The Assessment, Care in Custody and Teamwork process in prison, the care planning process for prisoners identified as being at risk of suicide or self-harm. It involves regular reviews, observations and recording of risks.
 
*SASH forms are the Suicide and Self Harm Warning Forms used for prisoners on transfer between custody. SASH is also the acronym used for relevant awareness training for staff.
 
The most recent inspection of Durham prison by HM Inspectorate of Prisons in late 2018, found that the ‘overriding concern was around the lack of safety in the prison’ and found it ‘disappointing to see that the response to recommendations from the Prison and Probation Ombudsman had not be addresses with sufficient vigour or urgency.
 
An independent review of progress by inspectors in July 2019 identified insufficient progress on recomendations relating to the management of prisoners at risk of suicide or self-harm, and responding to PPO recomendations.
 
The Ministry of Justice’s report ‘Safety in Custody Statistics, England and Wales: Deaths in Prison Custody to December 2018 Assaults and Self harm to September 2018’ published in January 2019 found that remand prisoners, and those serving indeterminate sentences, had a higher rate of self-inflicted deaths than those serving determinate sentences.