A MAN arrested while suffering a serious mental breakdown had been incarcerated at Chelmsford Prison for just seven hours before he took his own life.
An inquest into 40-year-old Stuart Berry found that the treatment he received from mental health services “possibly more than minimally contributed” to his death, a coroner has ruled.
Following the breakdown of his long-term relationship with the mother of his two young children, Mr Berry experienced a significant deterioration in his mental health and his cocaine misuse increased, the inquest heard. In 2023, Berry attempted to take his own life in a public park.
Mr Berry had been under the care of the Mental Health Urgent Care Department at Basildon Hospital after threatening suicide when he was arrested on January 26 2024, on suspicion of being involved in serious offences three days before.
At Grays Police Station he was assessed by a Health Care Practitioner (HCP) and, on her advice, later that afternoon received a mental health screening assessment by a Community Psychiatric Nurse (CPN).
He was deemed fit to be interviewed and following his police interview under caution, Mr Berry received a further welfare check from a paramedic after he reported hearing voices and was prescribed 5mg of Diazepam.
Having been charged with an offence, Mr Berry was remanded in police custody to attend court the following day.
Mr Berry was formally remanded into custody on January 27 at Chelmsford Magistrates and arrived at Chelmsford Prison around 2pm that afternoon.
A member of staff at Essex Partnership University NHS Foundation Trust (EPUT) who was based at the Magistrates court sent an email to the healthcare reception nurse alerting her to Mr Berry’s ‘extreme risk of suicide’.
However, at around 9pm that evening, during one of the twice-hourly observation checks by prison staff, Mr Berry was discovered hanging in his cell.
Coroner Sean Horstead said in his report there should have been a mental health review of Mr Berry at the MHUCD on the morning of January 26 2024. The report added that it was ‘inappropriate’ that he was discharged from MHUCD to the care of Essex Police, without a mental health review.
He said: “Taking the above points collectively, we consider the management of Mr Berry’s mental health by EPUT on January 26 and 27, 2024, possibly more than minimally contributed to Mr Berry’s death.”
He added: “The assessment and management of Mr Berry’s risk at HMP Chelmsford demonstrated serious failings. The whole process was severely impeded by poor completion of the ACCT and questionable input in respect of observations and conversations.”
Mr Berry was the seventh self-inflicted death at Chelmsford since February 2021. There has been one further self-inflicted death up to the end of June 2024.
A Prison Service spokesperson: “Our thoughts remain with the family of Stuart Berry. The prison has accepted all of the ombudsman’s recommendations and strengthened training and checks to make sure staff are properly identifying and supporting newly-arrived prisoners at risk.”
“The prison has accepted all of the ombudsman’s recommendations and strengthened training and checks to make sure staff are properly identifying and supporting newly-arrived prisoners at risk.”
Paul Scott, Chief Executive of Essex Partnership University NHS Foundation Trust (EPUT), said: “I want to apologise to Mr Berry’s family and friends for the failings in his care. We will thoroughly review the Coroner’s findings and respond.”
