Before HM Senior Coroner Terence Carney
Gateshead and South Tyneside coroners court
16 – 18 December 2019
The inquest into the death of Stephen Berry has concluded finding he died from the effects of alcohol withdrawal after being held in Northumbria police custody. The jury found symptoms of Stephen’s physical ill health should have been treated as a medical emergency and that had medical care been provided then his death may have been prevented. Shocking evidence on the behaviour of police officers was also heard at the inquest, at which the family were represented by another bereaved family member.
Stephen Berry was 43 years old when he died after becoming unresponsive in a cell at Washington police station. He had been held there for 27 hours, since 5pm on Thursday 28 March. Stephen spent a prolonged time in custody as the Friday was a Bank Holiday and the local court was closed until Saturday. He was pronounced dead in the Queen Elizabeth hospital in Gateshead at 12.39am on Saturday 30 March 2013.
His family were represented at the inquest not by lawyers but by another bereaved family member, after being unable to get through the protracted and painful application process for legal aid funding. Tracey McCourt and Stephen’s daughter, Gemma, connected online. Tracey supported Stephen’s family through the inquest and was recognised by the coroner as the family representative. She and the family were supported by INQUEST Head of Casework, Anita Sharma.
Stephen had a long history of mental ill health and alcohol dependency. He brought his daily medication and the instructions on when to take them with him to the police station. The inquest heard he was put in a cell monitored by CCTV and placed on observations which required him to be roused or spoken to every half an hour. However, there were a series of false entries and inaccuracies on the custody record when viewed against the CCTV footage. Throughout his first night in custody, Stephen was not visited or physically checked in any way for a total of four hours and 47 minutes.
The following morning on Friday 29 March 2013, Stephen reported to custody staff that he was hallucinating and shaking and requested to see a doctor who prescribed him some additional medication. However, his health continued to deteriorate and by the afternoon he was behaving in an increasingly distressed and disoriented manner.
Evidence was heard that by 7pm, Stephen was sweating profusely and demanding to be released. In the period that followed, he was seen to be talking to himself and gesticulating with his arms. CCTV  audio evidence was shown to the court which heard the conversations of the detention officers and police sergeant dismissing Stephen’s ill health and instead calling him “barking”, “fucking crackers” and a “fucking lunatic”.
The police sergeant spoke to Stephen through the hatch in the cell door at 7.26pm and was heard telling him “Listen you’re not going to hospital, you’re going to court in the morning.” Evidence was heard that the sergeant said Stephen had asked to go to hospital, but he thought it was an excuse to leave custody. At 8.25pm the detention officer recorded in the custody record that Stephen was ‘repeatedly banging on his cell door’ and said that ‘he can hear voices in his head and can see figures in his cell holding machine guns.’
At this point force doctor was finally contacted to request a mental health assessment. However, the detention officer did not mention that Stephen was hallucinating, sweating or hearing voices. Stephen’s condition continued to deteriorate. When the doctor rang back over an hour later at 9.46pm to check the urgency in attending the police station, the sergeant again did not mention any of Stephen’s symptoms. When force doctor finally arrived at 11.28pm, three hours after first being called, Stephen was seen on the CCTV to be curled on the cell floor, rocking back and forth. Upon arrival, the doctor instructed for an ambulance to be called.
The Independent Office of Police Conduct have today announced that gross misconduct proceedings will be brought against two custody sergeants who were responsible for Stephen’s welfare during his detention. However, both officers have left the police force since Stephen’s death.
Speaking exclusively to ITV News Tyne Tees, Gemma, Stephen’s daughter said: “It's had a huge impact on mine and my family’s life. My Nanna was dealing with it all previously, but she passed away in December three year ago and I promised her that I would keep fighting for justice for my dad. No-one should have been treated like he was in there. All the comments that were made towards my dad were totally disrespectful and unbelievable. He should have been given the chance to get taken to hospital when he asked to, instead of them dismissing him. He probably would have been still alive today.”

Tracey McCourt, sister-in-law of Leonard McCourt who died in police custody, and representing Stephen’s family at the inquest said: Having been through the process myself of representing my family following the death of my brother in law Leonard, I know how difficult this process is. I knew it would open some old wounds for me, but I also knew I couldn’t let Gemma do it on her own. It is an instinctive thing to do, as soon as you see someone struggling, I just have to help them.

People say the inquest process is ‘non-adversarial’. Well Gemma and I were up against three teams of state lawyers trying to obstruct and manipulate the process at every step of the way. The lawyers for the police were hoping to intimidate us, but I am glad we stood our corner to ensure we got to the truth about what happened to Stephen.

We would also like to thank the coroner and the jury who helped ensure that the failings that led to Stephen’s death would be thoroughly scrutinised. We both hope that no family has to go through what we have had to.”

Anita Sharma, Head of Casework at INQUEST said: “This inquest has shown a woeful lack of regard for the wellbeing of a man in crisis. The comments and inactions of the officers are disgraceful. Stephen was dehumanised and ultimately left to suffer by those who owed him a duty of care.
It is shameful that a bereaved family has had to represent another bereaved family at this inquest, a process which is inevitably retraumatising. Meanwhile they faced state bodies and representatives with unlimited access to public funding for experienced legal teams and experts. There must be automatic non means tested public funding to ensure families have immediate access to legal representation following a state related death.”



For further information, interview requests and to note your interest, please contact INQUEST Communications Team: 020 7263 1111 or [email protected]; [email protected]
The family are represented by Tracey McCourt and working with Anita Sharma, INQUEST Head of Casework.
The other Interested Persons represented at the inquest were:

  • Northumbria police
  • The police force doctor
  • Two custody sergeants

Legal aid for inquests
After applying to the Legal Aid Agency, Stephen Berry’s mother was awarded funding for legal representation at the inquest. When she sadly passed away in March 2017, the role of next of kin was passed on to Stephen’s daughter. At a time when she was grieving for both her father and grandmother. At her most vulnerable, she faced an intrusive, long and complex funding application process.
Stephen’s daughter was unable to complete this process at the time and, as a result, has been left without possibility of funded legal representation. Tracey McCourt is the sister in law of Leonard McCourt who died aged 44 after being pepper sprayed before collapsing in the back of a police van 2010. Tracey and Stephen’s daughter connected online, and Tracey is now supporting Stephen’s family through the inquest and is recognised by the coroner as the family representative. She and the family are being supported by INQUEST Head of Casework, Anita Sharma.

INQUEST is campaigning for automatic non means tested legal aid funding to families for specialist legal representation immediately following a state related death to cover preparation and representation at the inquest and other legal processes.
State bodies and representatives have unlimited access to public funding for the best legal teams and experts. This inequality of arms is an unacceptable curtailing of justice, undermining the preventative potential of inquests, to interrogate the facts and ensure harmful practices are brought to light.
INQUEST’s Now or Never! Legal Aid for Inquests campaign is calling for:

  • Automatic non means tested legal aid funding to families for specialist legal representation immediately following a state related death to cover preparation and representation at the inquest and other legal processes.
  • Funding equivalent to that allowed for state bodies/public authorities and corporate bodies represented.

Inquests following state related deaths are intended to seek the truth and expose unsafe practices. Yet families face multiple state lawyers, paid for at public expense, who frequently put defence of their interests above the search for the truth.
The Ministry of Justice published the final report of their review of legal aid for inquests on 7 February 2019. Despite long term, widespread support they rejected calls for fair legal aid funding.
A 38 degrees petition has since received 95,000 signatures, demonstrating clear and widespread public support around this issue.
The call for legal aid for inquests following state related deaths has been backed by numerous independent reports and public bodies, dating back as far as the 1999 Macpherson report. See the timeline of official support from 1999-2019, the briefing on legal aid for inquests and campaign page for more information.

Other relevant cases:
Mark Needham, 52, died in July 2015 after having five seizures in Northumbria police custody. The inquest heard that Mark was prone to seizures when withdrawing from alcohol. The jury concluded that errors by sergeants and a police nurse contributed to his death. The coroner raised concerns about the risk of custody staff becoming ‘desensitised’ to drunk people and missing deteriorating health conditions as a result.