THERE was little to indicate a Chelmsford HMP prisoner was at imminent risk of suicide before he was found unresponsive in his cell, a report has determined reports the Local Democracy Reporter.
But a number of factors following previous suicide attempts, self-harm and substance misuse indicated Daniel Beresford was nonetheless at some risk.
The 36-year-old had been sentenced to four years in 2022 for burglary and theft. He was to be released on licence from HMP Ranby on April 20, 2023, but Mr Beresford’s licence was revoked when he allegedly committed further offences of aggravated vehicle taking and driving while disqualified.
Mr Beresford was remanded to custody and taken to HMP Chelmsford on June 20, 2023. He had had a long history of self-harm and had previously attempted suicide 14 times between 2012 and 2022, both inside and outside of prison. He also had a history of accidental overdose.
However, a report from the Prisons and Probation Ombudsman said that in contrast to his previous periods in prison, Mr Beresford did not attempt suicide or self-harm while at Chelmsford.
It added he appeared to be settled on his wing, had done well on a graphics course he was on and had a trusted job.
Mr Beresford had been concerned about the reduction in dosage of his diazepam, prescribed for anxiety and epilepsy, but his psychiatrist had increased his dose two weeks before he died, and the report said he appeared happy with that decision.
Two prisoners told the investigator that Mr Beresford had talked about ending his life but did not tell staff.
Although some of Mr Beresford’s friends thought he had been in a low mood, others did not, and his partner had no concerns about him when she last spoke to him on October 11.
The report from Adrian Usher added: “We consider that there was little to indicate that Mr Beresford was at imminent or heightened risk of suicide at Chelmsford before October 13.”
Mr Beresford’s was the sixth self-inflicted death at Chelmsford since October 2020. By the end of April 2024, there were two more self-inflicted deaths at the prison.
Mr Beresford admitted to buying illicit pregabalin, used by doctors to treat epilepsy and anxiety, on the wing and said he would continue to do so until he received the correct dose of diazepam.
But after his diazepam was increased, he told staff he was no longer buying pregabalin.
Mr Usher said: “Mr Beresford had a significant history of attempted suicide, self-harm and substance misuse.
“He appeared to be doing well at Chelmsford and, overall, I am satisfied that there was little to indicate that he was at imminent risk of suicide in the period leading to his death.
“My investigation found an issue with diversion of prescribed medication and some deficiencies in substance misuse support procedures. I did not find that any of these issues affected Mr Beresford’s death.”
However, he added: “Although we have seen no evidence that it affected his death, we are concerned that Mr Beresford was able to access pregabalin with apparent ease at Chelmsford.
“This is most likely to have been diverted medication prescribed to another prisoner.
“We are satisfied that the prison is now actively monitoring diversion and is taking appropriate steps to reduce it. We therefore make no recommendation.”
