25th September 2017

Before HM Coroner Ian Pears
Bedfordshire and Luton Coroner Service
The Court House Woburn Street Ampthill  Bedfordshire MK45 2HX

Opens 26 September 2017 – expected to last 7 days


On Tuesday 26 September, an inquest hearing will open into the death of Mark Vagnoni, 35, who was found hanged in his cell at HMP Bedford. His was the second of four self-inflicted deaths at the prison that year. There have been two further self-inflicted deaths in 2017. A HMIP Inspectorate Report conducted in May 2016 found that conditions in the prison had declined to "unacceptable levels." In November 2016, there was a riot at HMP Bedford, involving 230 prisoners.

Mark Vagnoni suffered from schizophrenia, and was under the care of the Community Mental Health team prior to his remand.  Before his death, Mark had repeatedly sought help from the mental health team at the prison.  On 11 July 2016, Mark was seen by a prison officer running his bedsheets through his fingers. He was found hanging in his cell less than 15 minutes later.

Key issues for the inquest include:

• Whether suicide and self-harm prevention procedures were used when they should have been, and whether they were used appropriately
• The adequacy of risk assessment by the mental health team
• Information sharing between prison officers and the mental health team

Very similar issues have arisen in relation to other self-inflicted deaths at HMP Bedford. As a consequence, the prison has agreed to implement new annual training to staff in relation to the management of prisoners at risk of self-harm.

The family is represented by INQUEST Lawyers Group members Jessie Waldman of Bhatt Murphy Solicitors and Jesse Nicholls of Doughty Street Chambers. INQUEST has been working with the family of Mark Vagnoni since November 2016.




For further information, please contact Natasha Thompson on 0207 263 1111 or email [email protected].

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. Our specialist casework includes death in police and prison custody, immigration detention, mental health settings and deaths involving multi-agency failings or where wider issues of state and corporate accountability are in question, such as the deaths and wider issues around Hillsborough and Grenfell Tower. Our policy, parliamentary, campaigning and media work is grounded in the day to day experience of working with bereaved people.

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