Stephen Beadman: Prevention of future deaths report

Mental Health related deathsState Custody related deaths

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Date of report: 23/06/2023

Ref: 2023-0210

Deceased name: Stephen Beadman

Coroner name: Kevin McLoughlin

Coroner Area: West Yorkshire (Eastern)

Category: State Custody related deaths | Suicide (from 2015)| Mental Health related deaths

This report is being sent to: HM Prison Wakefield, Ministry of Justice and NHS England


HM Prison Wakefield, [REDACTED] , Governor
Ministry of Justice – Rt Hon Alex Chalk KC MP, Lord Chancellor and Secretary of State for Justice
NHS England, Quarry House, Quarry Hill, Leeds, LS2 7UE
I am Kevin McLoughlin, Senior Coroner, for the Coroner area of West Yorkshire (East).
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
On 20th April 2021 I commenced an investigation into the death of Stephen Kurt Beadman, aged 34. The investigation concluded at the end of the Inquest on 21st June 2023. The conclusion of the Inquest was a Narrative which included a finding that Mr Beadman committed suicide having been bullied by other prisoners.

Mr Beadman, aged 34, was serving a long sentence at HMP Wakefield.  

He had repeatedly complained of being bullied and was in fear that a ‘contract’ was out on him following suspicions that he was an informer. He had a long history of self- harming.  

On 7th April 2021 around 2:30pm he barricaded himself in his cell and inflicted wounds [REDACTED] issued to him by the prison which he was entitled to have in his possession in his locked cell. An ACCT was opened that afternoon as he was in an agitated state. He was seen at 4pm and 4:30pm but at 5:05pm he was found in an unresponsive state with a neck ligature applied to his neck. He died in hospital the following day, 8th April 2021.

Mr Beadman, aged 34, was a serving prisoner at HMP Wakefield. He had been diagnosed with a mixed personality disorder along with mixed depression and anxiety. He was prescribed medication. He had a long history of self-harm and in 2020-21 repeated suicide attempts. On 7th April 2021 he was found in an unresponsive state having applied a ligature to his neck. He died the following day, 8th April 2021 in hospital from:

1(a) Hypoxic Ischaemic Encephalopathy
1(b) Cardiac Arrest
1(c) Hanging

During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.  

The MATTERS OF CONCERN are as follows.
1. Mr Beadman had a history of self-harming [REDACTED]. Nonetheless, he was permitted [REDACTED] in his possession when alone in his cell.  

2. For the avoidance of doubt, Mr Beadman took his own life later in the afternoon of 7th  April 2021 by applying a ligature to his neck, [REDACTED] to take his own life.  

3. The issue of [REDACTED] gives rise to a foreseeable risk.  

4. Only six weeks before the 7th April 2021 incident, another prisoner, Carl Shaun Langdell had used a similar type of [REDACTED] to inflict a fatal wound to his neck. A Prevention of Future Death Report dated 21.10.22 was made in that case. A copy is attached, along with the response received from [REDACTED] dated 23.12.22.

5. Evidence was taken at the Inquest in which several people working at the prison expressed support for such [REDACTED] to be withdrawn from use in the prison.
6. It is acknowledged that consideration has been given within the prison service nationally to the withdrawal of [REDACTED] of this type and that this work (including various pilot projects) is ongoing. It is further acknowledged that the difficulties in identifying a workable alternative system of male grooming are considerable. This does not, however, obviate the need to remove a clear source of potential harm from those with an identified history of self-harming.

The MATTERS OF CONCERN are as follows.
1) Evidence was taken at the Inquest to the effect that HM Prison, Wakefield is a maximum-security prison which houses some 750 men, many of whom have significant mental health or addiction issues.

2) Despite this complex cohort of prisoners, the prison only has one day per week of consultant psychiatrist resource. As the professed principle is equivalence of care with the community, this seems not to be achieved, particularly having regard to the psychological make up of the prisoner population.

3) Evidence taken at the Inquest indicated that further senior psychiatric doctor resource would enable the prison to provide better for the needs of the prisoners.

4) For the avoidance of doubt, it is accepted that Mr Beadman himself was able to see the consultant psychiatrist on 19th October 2021 for 1 hour and again on 25th January 2021 (at which time he was discharged). Notwithstanding that his death on 8th April 2021 cannot be attributed to a lack of psychiatric attention, there is a concern that other long-term inmates in the prison are not receiving the specialist care they probably need. This in turn gives rise to a concern that other deaths may occur.

5) The Inquest was informed that NHS England are currently reviewing the provision of psychiatric resource at HM Prison, Wakefield. It is hoped that this report can be taken into account during this review.
In my opinion action should be taken to prevent future deaths and I believe you and the Prison Service have the power to take such action.
You are under a duty to respond to this report within 56 days of the date of this report, namely by 2nd September 2023 (to take account of the impending holiday season). I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons:
1)        [REDACTED] , Mother of Stephen K Beadman
2)       Practice Plus Group, [REDACTED]
3)       Midlands Partnership University NHS Foundation Trust, [REDACTED]

I have also sent it to: 
1)        [REDACTED] , Governor, HMP Wakefield
2)       [REDACTED] , Government Legal Department who may find it useful or of interest.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest.
You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.
9Kevin McLoughlin Senior Coroner, West Yorkshire (East)
Dated: 23rd  June 2023