On g" July 2013 commenced an investigation into the death of Seweryn Witold Glowinski then aged 25 years. The investigation concluded at the end of the inquest on 15"h October 2014_ The conclusion of the inquest was a narrative conciusior the medical cause of death being hanging

Mr Glowinskl was a serving prisoner at HMP Long Lartin in Worcestershire_ He was diagnoised with paranoid schizophrenia and for his own protection was transferred from normal location into the segregation wing Although it was anticipated he would only be on segregation for a matter of days he stayed there for a little under a fortnight; He was found hanging in his cell on the evening of 3'd July 2013. Mr Glowinski was the subject of an open ACCT because of self-harm_ CORONER"S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern: In my opinion there is & 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 (1) There appeared to be no communication between the Residential Wing and the Segregation Unit as to the plan for Mr Glowinski. It appeared that the Segregation staff were unaware that the wing staff wanted to have him risk assessed for a move t0 another location and in fact the risk assessment was not commenced until the before his death, (2) The documents_to_revlew and authorise his further detention in the Segregation Unit the day were completed by the way 0f "cutting and pasting" from other prisoners files: It was clear that the information on Mr Glowinski's paperwork was incorrect and had been transposed from another prisoner, (3) Senior Custodial Managers In the wing were unaware of Ihe requirements of prison service orders which meant that an individual on an open ACCT should not be transferred to segregation unless there were exceptional reasons for SO_