Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2026-0038, written 20 Oct 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 20 Oct 2025 |
|---|---|
| Reference | 2026-0038 |
| Deceased | Scott Berry |
| Coroner | Sarah Middleton |
| Coroner area | City of Kingston Upon Hull and the County of the East Riding of Yorkshire |
| Category | State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Minister of State for Prisons, Parole and Probation 1 CORONER I am Miss Sarah Middleton, Assistant Coroner, for the Coroner Area of City of Kingston Upon Hull and the County of the East Riding of Yorkshire. 2 CORONER’S LEGAL POWERS 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. 3 INVESTIGATION and INQUEST On 26th October 2023 I commenced an investigation into the death of Scott Stepjhen Berry aged 37 years. The investigation concluded at the end of the inquest on 13th October 2025. The Inquest was heard with a Jury. The narrative conclusion of the inquest was: Mr. Berry deliberately chose to suspend himself , but the evidence does not fully explain whether or not he intended that the outcome be fatal. CIRCUMSTANCES OF THE DEATH as determined by the Jury 4 At the time of his death, Mr. Berry had been in prison for 15 years serving an IPP with several unsuccessful parole applications. Mr. Berry had a long-standing history of mental health problems and diagnosis of emotionally unstable personality disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder and anxiety. The effects of these were heavily exacerbated by Mr. Berry's' sense of injustice regarding his IPP sentence, which he spoke about frequently to prison, healthcare and other staff. On 12th October 2023, it was Mr. Berry's late Father's birthday and Mr. Berry was displaying low mood and made statements about wanting to take his own life. An ACCT was appropriately opened to monitor Mr. Berry at a high frequency. Mr. Berry was checked at 18:32 and again at 18:52 at which time he was found hanging Mr. Berry was attended to by prison and healthcare staff and was successfully resuscitated after CPR. Paramedics attended and Mr. Berry was taken to Hull Royal Infirmary where he was treated by hospital staff, but due to sustaining a hypoxic brain, he died on 21st October 2023. Although, Mr. Berry was found to have taken on hospital admission, there is not enough evidence to suggest that Mr. Berry was under the influence of in his system from the blood samples on 12th October 2023. 1 5 CORONER’S CONCERNS 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: Mr Berry was one of many Imprisonment for Public Protection (IPP) prisoners at HMP Humber. Mr Berry was frustrated by his sentence and had little hope of being released which he voiced to a number of staff and professionals. Mr Berry had been sentenced to a tariff of 2 years and 4 months and was till in prison 15 years later. These sentences were abolished in 2012. I have had regard to the HMPPS Action Plan for those on Imprisonment for Public Protection sentences and the strategy to address the challenges faced by IPP prisoners. In evidence I heard that the Action Plan is assisting those on such sentences in the community. The numbers of prisoners on licence has fallen. However, there still remains a large number of unreleased IPP prisoners in prison. For those who remain detained in prison, some many years after their original tariff, there is still a long period for them to wait for a review. These prisoners are, in many cases, still waiting for parole board review and not all have access to Offender Delivery Programmes or therapeutic and progression units to assist them. These prisoners are suffering with their mental health and still have little hope of release. If action is not taken with regard to those still serving these sentences in prison, then there is a risk of future deaths occurring. The making of a Regulation 28 report in this regard was supported by the Safer Custody team at HMP Humber so that a considered response can be provided in relation to this matter and the concerns raised. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation has the power to take such action by ensuring thorough safeguarding reviews take place and all parties are notified of the conclusion and involved fully in the process. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 15th December 2025. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons; the family of Scott Berry, HMP Humber and Spectrum Healthcare. I have also sent it to: The Prison and Probation Ombudsman HM Inspector of Prisons 2 Executive Director of Inquest I am also under a duty to send the Chief Coroner a copy of your response and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. 9 Dated: 20th October 2025 3
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Director General Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ Sarah Middleton HM Assistant Coroner for City of Kingston Upon Hull and the County of the East Riding of Yorkshire The Guildhall Alfred Gelder Street Hull HU1 2AA 15 December 2025 Dear Ms Middleton, Thank you for your Regulation 28 report of 20 October 2025 addressed to the Minister for Prisons, Probation and Reducing Reoffending, following the end of the inquest into the death of Scott Berry on 13 October 2025. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General Operations. I know that you will share a copy of this response with the family of Mr Berry and I would like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. Following evidence heard at the inquest, you have raised concerns about those still serving the IPP sentence in prison, in many cases several years after they completed their minimum term (tariff). Before I address those concerns, I should affirm that HMPPS remains fully committed to supporting the progression of those prisoners serving IPP sentences to the point where the independent Parole Board determines that they may be safely released. As you will be aware, the IPP sentence was introduced in the Criminal Justice Act (CJA) 2003 and was abolished in late 2012 by the Legal Aid, Sentencing and Punishment of Offenders Act 2012. This abolition was not applied retrospectively, as the Government at the time took the view it would not be right to alter sentences that had been lawfully imposed prior to their abolition. It is important to note that courts could only impose an IPP sentence for specified serious offences listed within Schedule 15 of the CJA 2003. It is for the independent Parole Board to determine whether any prisoner serving an IPP sentence may be released on licence, once they have completed the minimum period of imprisonment set by the Court at the point of sentence. In order to direct the prisoner’s release, the Parole Board must be satisfied that it is no longer necessary for an individual to be confined in prison for the protection of the public. As of 30 September 2025, the number of IPP prisoners was 2,422, down from 2,694 the year before – a reduction of around 10%. Of those, 946 had never been released (down from 1,095 the year before) and 1,476 had been recalled to custody (down from 1,599 the year before). In 2024 there were 619 recalls, the lowest since 2017. We expect the number of IPP recalls to fall further due to the significant reduction of those serving IPP sentences in the community. 602 IPP re-releases, following recall, were recorded in 2024, the highest number in a given year and over a third more than in 2023. I note that you raised concerns that IPP prisoners are waiting for a Parole Board review. The priority when listing cases is a matter for the Independent Parole Board. Nonetheless, HMPPS updated the Generic Parole Process Policy Framework in February 2025 and introduced a presumption for an 18-month period between parole reviews for IPP prisoners and 12 months for DPP (youth equivalent of IPP sentence) prisoners1. The Parole Board has established an IPP Taskforce to manage cases. It aims to reduce the time it takes an IPP case to go through the parole system by sending the most complex cases straight to oral hearing, allowing for reports to be directed earlier. The Taskforce is made up of 25 members, including specialist psychologist and psychiatrist members. All members of the taskforce have considerable experience in reviewing and managing IPP prisoners’ cases. They are further supported by 20 case managers who provide an enhanced level of case management support for those members2. The Government is determined to support the rehabilitation of IPP offenders through a refreshed IPP Action Plan, which we published on 17 July 2025. The Plan puts an important emphasis on effective frontline delivery in our prisons and the Probation Service, to ensure that those serving IPP sentences have robust and effective sentence plans and that they are in a prison most appropriate to their needs. This is the most effective way to help them to reduce their risk so that they can progress towards safe release from custody. I have provided a list in Annex A which details some of the operational measures we are taking to support the IPP cohort. The refreshed Action Plan was published in our IPP Annual Report and can be accessed using the following link: https://www.gov.uk/government/publications/hmpps-annual-report- on-the-ipp-sentence-2024-to-25. , Area Executive Director for the South West, South Central & Our IPP Action Plan is led at Director level to ensure there is senior accountability for its delivery. Public Protection, has taken this lead role. He established the IPP Progression Board in June 2023, and is the Chair. The Board meets on a quarterly basis and is used to hold all workstream owners to account for their delivery of actions within the Action Plan. is also Chair of the External Stakeholder Challenge Group, which was established in September 2023. The Group ensures that the work we are delivering is subject to regular scrutiny and accountability from key campaign groups and independent bodies. I note that the Prisons and Probation Ombudsman (PPO) completed their independent investigation into the death of Mr Berry. The PPO’s report3, published in June 2024, found that staff managed Mr Berry’s risk of suicide and self-harm appropriately and that Mr Berry received a good standard of care and support from prison and healthcare staff during his time in prison. I can assure you that reducing the number of self-inflicted deaths in custody is a key priority for me and HMPPS. Staff work hard to identify and support prisoners at risk of suicide and 1 https://www.gov.uk/government/publications/generic-parole-process-policy-framework 2 https://www.gov.uk/government/publications/hmpps-annual-report-on-the-ipp-sentence- 2024-to-25 3 https://cloud-platform- e218f50a4812967ba1215eaecede923f.s3.amazonaws.com/uploads/sites/14/2025/10/F6675- 23-Death-of-Mr-Scott-Berry-in-hospital-Humber-21-10-2023-SI-31-40-37.pdf self-harm. HMPPS Safety Team has a dedicated team member who focuses on the safety of IPP prisoners. In May 2023, the Safety Team produced a learning bulletin sharing early learning from the self-inflicted death of IPP prisoners. The bulletin provided guidance for suggested actions staff can take, including the importance of considering IPP prisoners’ heightened level of risk. In November 2023, the Safety Team delivered a safety briefing to front-line staff to further raise awareness on the risks of IPP prisoners. Two further sessions were also held during a dedicated ‘IPP in Focus’ weeks in April 2024 and September 2025, both of which were attended by high numbers of staff. The sessions during these weeks were all recorded for wider dissemination to prisons and probation delivery units across England and Wales. The Safety Team have also developed a Safety Toolkit, with a range of learning and practice materials to help front-line staff support those serving the IPP sentence effectively, recognising the heightened level of risk of self-harm and suicide among IPP prisoners. Our refreshed IPP Action Plan has a workstream dedicated to Safety with the main objective of supporting prisons to deliver improvements to the safety of those serving an IPP sentence by actively identifying and supporting IPP prisoners at risk of self-harm and violence in custody, whilst supporting their engagement and progression. Our primary focus is on raising awareness of the heightened risk of self-harm and suicide of IPP prisoners so all staff understand the risk factors and can provide effective support. We will continue to monitor, analyse and share any changing or emerging trends in published IPP prisoner data with staff and to inform and update our guidance where appropriate. The Victims and Prisoners Act 2024 received Royal Assent on 24 May 2024 and introduced significant changes to the IPP licence. This included reducing the qualifying period for consideration of licence termination from 10 years after first release to three years (or two for those serving a DPP sentence), introducing a provision for automatic licence termination and enabling the Secretary of State to re-release a recalled IPP offender under the Risk Assessed Recall Review (RARR) power. These changes resulted in the automatic termination of 1,742 IPP licences on 1 November 2024. A further 600 people became eligible for referral to the Parole Board to consider licence termination on 1 February 2025. So far, the number of people serving the sentence in the community has fallen by two-thirds following the implementation of these changes. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address the matters that you have raised. Yours sincerely Director General Operations Annex A - IPP Operational Measures Working Toward Release • Focus on getting 90% of IPP prisoners into the right prisons for their needs. • Many prisons are running IPP Forums to provide peer support to those serving the sentence. Through the Action Plan we will continue to build on this good practise and deliver more Forums across the estate • HMPPS conduct a six-monthly RAG (Red, Amber, Green) rating exercise to identify which IPP prisoners are most struggling to progress, so that support can be targeted. • We published the Progression Panel Policy Framework in July, and have already seen a significant number of panels recorded. These panels, comprising of HMPPS staff and wider partner agencies, ensure that those serving IPP sentences are on the right progression pathway, with access to the right interventions, at the right time. • HMP Aylesbury is in the process of creating the Phoenix Unit, which will be a bespoke unit dedicated to support IPP prisoners with a red RAG rating who are struggling to progress in their sentence. • Psychology have rolled out a case review process to ensure that attendance at progression panels is supported by a thorough review of the case and targeted preparation to help optimise the panel. • HMPPS Psychology Services is completing light touch quarterly reviews on DPP prisoners to ensure a regular review of the RAG rating and barriers to progression are considered. Continued Support After Release • Expansion of the Approved Premises (AP) pilot which provides in reach work to IPP prisoners to support them to transition to the AP, and allows a longer stay for individuals. This was piloted at 4 sites in the North West and is being rolled out to a further 11 sites across England and Wales. • Psychology Services are delivering an IPP Community Pathway (which has expanded for all cases now but started with IPP sentenced individuals). This is focused on consultancy, staff support and training for probation/AP staff, as well as completing discrete research projects. All of which is important for through the gate working, handover of cases and alternatives to recall. Recall • HMPPS have streamlined recall documentation and added a direct request to consider suitability for Risk Assessed Recall Review (RARR) ensuring that the potential for a swifter re-release is firmly in the mind of the Probation Officer completing it. • All IPP recalls are considered for suitability for RARR • Refresher training has been delivered to PPCS senior managers on the causal link. • The recall template is going to be updated to capture the causal link more clearly. • The recall referral trial has begun; this will extend the period of time in which IPP prisoners must be referred to the Parole Board following recall with the intent of allowing more time for consideration of RARR. Communications, Training and Engagement • The Public Protection Group (PPG) and Psychology Services are working together to review existing training packages and set up a central shared folder with links to all training relevant to the management and progression of those serving the IPP sentence to make training easier to access. Through this process we will also address any gaps in training provisions. • Psychology Services have also completed a number of IPP Continued Professional Development (CPD) events and teach ins across the estate. • HMPPS are creating an IPP Communications Strategy. IPP prisoners have been consulted on this, and throughout December/January external stakeholders will have the opportunity to provide thoughts and feedback. We will publish this internally in the new year. This will set out objectives to ensure policy changes and important messages reach the entire intended audience (both prisoners and staff), and methods for testing that communications have been successful. • There have been a number of IPP events recently including at The Verne and Littlehey providing opportunity to share examples of good practice. There are more IPP events due to take place in the New Year. • Annual IPP Scrutiny Panels looking into Area Delivery Plans took place in February 2025 and will take place again week commencing 23rd February 2026.
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