The inquest into the death of Steven Hart lasted 8 days between 30th June- 9th July 2025.

On 30th November 2022, Steven Hart was remanded to HMP Bedford. From his arrival, it was well evidenced that he had a history of mental health issues including previous self harm attempts. Between December 2022 and March 2023, Steven Hart displayed varying degrees of mental health issues, including two episodes of self-harm, and paranoia. He was placed on ACCTs following these incidents, and supported by some prison staff who he had formed close relationships with.

On 12th March, a further ACCT was opened due to Steven having thoughts of self-harming and restlessness. Between the 18th March-20th March 2023, the wing that Steven was staying on was put into a state of lockdown. The Jury heard evidence that Steven relied on routine in stabilising his mental health; the ability to go to the gym, to work, and take his medication were all impacted by this lockdown, and unfortunately Steven’s mental health declined during this period. A mental health assessment for Steven was not able to take place during this time.

Following a further incident of self-harm on 19th March 2023, where Steven had expressed suicidal ideation, he was received into the healthcare wing and placed on an ACCT, involving constant supervision. During this time Steven alluded to future self-harm via ligature; testimony from staff stated that not everyone was made aware of this comment, despite being documented on NOMIS records.

Despite a self-harm attempt on 22nd March 2023, Steven was moved to a safer cell on 23rd March 2023, and placed on reduced observations of 4 irregular observations per hour. Razors had been removed from Steven, and the cell was ‘ligature proof.’ Witnesses told the Jury that Steven was presenting much better; he had tidied his cell, he was engaging with officers in observations, and was looking forward to his future.

On 25th March 2023 at 17:02, an officer was seen on CCTV to remove a telephone cord from Steven’s cell, where Steven had been using the cord to ligature. The officer stated he had attempted to report the incident to OSCAR 1, in line with protocol, however evidence found that OSCAR 1 was not informed and the officer by his own admission conceded he had in fact, not called OSCAR 1. Neither officers present at the time attempted to contact OSCAR 1, and the Jury heard that staff did not receive this information in the evening handover.

At 21:04 on 25th March 2023 an officer on duty noticed a ligature on Steven’s cell door, attached to the metal panel. The officer called for assistance, where Steven was found unresponsive. Paramedics arrived at 21:19 and convoyed Steven to hospital. Unfortunately, Steven sadly passed away in hospital on 29th March 2023.

The Jury concluded that Steven died due to asphyxiation by hanging. They found the following failings of the prison:

  • Failure to carry out mental health assessment between 18th-20th March 2023 did not allow the opportunity for further actions or support to be put into place for Steven.

  • Failure to share relevant concerns between staff regarding Steven’s comments to ligature.

  • Failure by staff to read and review documents relevant to Steven’s well-being, such as NOMIS entries.

  • Failing within the prison to allow the opportunity for proper handovers, including verbally sharing key information and reading and reviewing ACCT document.

  • Failure to inform OSCAR 1 of the ligature attempt did not allow for the opportunity for OSCAR1 to review Steven’s presentation and activate further actions of support.

  • Failure to give a full handover on the evening of 25th March 2023 led to inadequate understanding of Steven’s mental health presentation.

  • Lack of further ACCT following the telephone cord incident meant that items were not removed from Steven which could have been used to self-harm or attempt suicide.

  • The CCTV footage showed that the 4 hourly observations on the 25th March 2023 were not carried out to the proper standard.

  • Failure to inform the healthcare team of the telephone ligature attempt.

Throughout the inquest hearing, various members of Steven’s family were present, including his mother, siblings, and wider family members. It was heard from staff members that Steven had a great love for his family, and they were a stabilising force for Steven during his time at prison. Steven’s family remember him as a loving, hard-working, and family-oriented man, with a ‘heart of gold’.

Steven’s family were represented at the inquest by Kelly Darlington of Farleys Solicitors and Laura Herbert of Crucible Law.

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