7th April 2017

Coroner Jonathan David A Leach
Wakefield Coroners Court
20 March-6 April 2017

The second recent inquest into a self-inflicted death in the segregation unit of HMP Leeds concluded yesterday. The Jury returned a highly critical narrative conclusion at the inquest of Chris Beardshaw, aged 37. His death came just five months after Matthew Stubbs’, who also died in the segregation unit. Since Chris’s death in December 2013 there have been 10 self-inflicted deaths in HMP Leeds, the second highest rate in any prison in England and Wales (3).

Chris Beardshaw had been on remand in the prison for four months. He had no previous mental health concerns. On the day he died, Chris and another prisoner were caught in an alleged attempt to bring contraband into the prison. They were taken to the segregation unit to be searched and held, pending adjudication.
Chris was compliant, however once in the cell he expressed concerns about the poor conditions and smell of excrement. Prison staff checked and felt the condition of the cell was satisfactory, and Chris was not moved despite other cells being available. As a result, he became distressed and made around 40 cuts to his arm using the plastic knife provided for his meal. Staff then took measures to address safety concerns, placing Chris on an open ACCT document (4), removing furniture and replacing his clothes with what officers believed was anti-tear clothing.

The Jury found that adequate steps were not taken to monitor Chris, concluding that staff were not properly trained, and criticising the quality of the ACCT observations and communication between officers. It was also confirmed that one prison officer had not carried out an observation, despite recording it in the paperwork.
HM Area Coroner Jonathan Leach advised he would be making a Prevention of Future Deaths report due to concerns in this case around the absence of guidance on placing someone in segregation under exceptional circumstances.

Chris Beardshaw’s family (5) said:
“We believe Chris’s death was completely avoidable. Chris was so optimistic and working hard to get his life on track. We do not believe he wanted to die; he just wanted someone to listen to him, it was a cry for help. After listening to three weeks of evidence we believe that there were failings in Chris’s care and we hope that the prison acts upon those issues brought to light in the inquest to prevent other families experiencing the heartache we have.”

Komal Hussain, a trainee solicitor at Minton Morrill Solicitors said:
“It is unacceptable that HMP Leeds has failed Chris and his family by failing to follow policies and procedures designed to protect the lives of vulnerable people within prisons. Chris’s death is another example of HMP Leeds inappropriately managing prisoners in the segregation unit. It is unfortunate that the prison sees locating prisoner’s on ACCT’s in segregation as the norm rather than the exception. It is highly concerning that staff lacked knowledge in understanding that Chris’s circumstances meant he should be observed 5 times per hour. This death continues to highlight the ongoing concerns within HMP Leeds and its nature of deviating from policies and procedures put in place to safeguard vulnerable prisoners.

Deborah Coles, Director of INQUEST said:
“Once again an inquest has criticised the failure of HMP Leeds to protect those in its care, despite repeated recommendations and opportunities for learning. The conclusion of this inquest adds to ongoing concerns about a lack of mental health training in prisons, and the high level of self-inflicted deaths in HMP Leeds and across the prison estate.
“Segregation is the worst place for vulnerable people. In Chris’s case the prison staff chose to isolate him and deny him of any mental stimulus after he expressed distress, self-harmed and had been identified as at risk. HMP Leeds has one of the highest rates of self-inflicted deaths in the country, so efforts to effect real change must be made urgently before we see yet more preventable deaths.”

INQUEST and Minton Morrill Solicitors have been working with the family of Chris Beardshaw since December 2014. The family is represented by Solicitor Gemma Vine from Minton Morrill Solicitors and barrister Richard Copnall from Park Lane Plowden Chambers in Leeds.




For further information, please contact: Lucy McKay on [email protected] or 020 7263 1111

  1. Chris Beardshaw died on 30 December 2013, age 37.

    2. Matthew Stubbs also died in the segregation unit of HMP Leeds in 2013. More info here.

    3.  Since 2013 HMP Leeds has had the second highest number of self-inflicted deaths in prison, after HMP Woodhill. There is currently ajudicial review, brought by the families of the deceased at HMP Woodhill, aiming to address the high number of self-inflicted deaths.

    4. ACCT documents are the Assessment, Care in Custody and Teamwork (ACCT) Review, and are opened when there are concerns about a prisoners’ mental health.

    5. The family wish to remain anonymous.


INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.