Dear Ms Malhotra,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR PATRYK GLADYSZ

Thank you for your Regulation 28 report of 18 July 2025 following the inquest into the death of Patryk Gladysz at HMP Wandsworth on 19 January 2024. My response will cover those issues that are within the remit of [ ] HMPPS.

I know that you will share a copy of this response with Mr Gladysz’s family, and I would first 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.

You have expressed concerns regarding staffing at HMP Wandsworth and the impact on delivering the key worker scheme, operational staff’s knowledge of the heightened risk of Foreign National Offenders (FNO), the delivery of roll checks and Assessment, Care in Custody, Teamwork (ACCT) observations, and the communication between prison and healthcare staff.

I have received assurance from the Governor of HMP Wandsworth that there has been improvement in staffing figures and that there is evidence of a higher retention rate as the months progress. There has been a recent recruitment intake which has added to the existing staffing group and has elevated HMP Wandsworth’s prison officer levels to above the target staffing figure.

HMP Wandsworth now has an assigned Custodial Manager to provide robust oversight of allocation, training and data of the keyworker scheme. The data is shared weekly during the

morning meeting to provide consistent management oversight. Additionally, prisoners who are deemed to be higher risk are automatically assigned a keyworker to ensure they are provided with adequate support at the earliest opportunity. The combination of improvement in staffing and the allocation of managerial oversight to the keyworker scheme will contribute to an improvement in its delivery.

HMP Wandsworth are working collaboratively with Catch 22 to improve the support given to FNOs whilst in custody. This includes facilitating a bespoke induction plan and translating all information available to prisoners into the ten most common languages to ensure all FNOs have equal access. Prison staff are made aware during their initial ACCT training of the groups of prisoners who are at heightened risk of self-harm and suicide, such as FNOs. This includes recognising risks in a prisoner’s history and their presentation, rather than relying solely on verbal information received from the individual. This information is now also regularly communicated to prison staff during briefings.

Prison staff have received briefings with regards to their responsibilities during roll checks, including the need for timely completion and the requirement for a response to be gained from the prisoner to ensure their wellbeing. This has resulted in an improvement in documented roll check timings. The Governor of HMP Wandsworth has now also implemented a monthly assurance check, which cross references documented ACCT observations against CCTV footage. Appropriate action is taken against any member of staff who does not complete these checks in line with national policy.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.

Dear Madam, Regulation 28 Report to Prevent Future Deaths – Inquest touching the death of Mr Patryk Gladysz Thank you for your regulation 28 report to prevent future deaths dated 18th July 2025 following the inquest into the death of Mr Patryk Gladyz which concluded on 15th July 2025. In advance of responding to the specific concerns raised in your report, I would like to express my deep condolences to Mr Gladyz’s family and loved ones. Oxleas NHS Trust is keen to assure the family and the coroner that the concerns raised about Mr Gladysz’s care have been listened to and acted upon.  I appreciate that responses to Coroner Reports may constitute an important part of process through which family and friends come to terms with the passing of their loved one, and that this will have been an incredibly difficult time for them. In paragraph 5 of your letter, you raised concerns in relation to the care provided to Mr Gladyz whilst at HMP Wandsworth, namely:
1. Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.
2. Staffing within HMP Wandsworth resulting in a dilution to the requirements for the key worker scheme.
3. Knowledge of prison staff of the heightened risk of foreign nationals in custody, despite a higher proportion of foreign nationals being detained at HMP Wandsworth.
4. Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use – 21 healthcare accounts were de-activated notwithstanding an increase in available terminals.
5. Prison officer checks of roll calls/ACCT observations - recent audit by HMP Wandsworth suggests on-going challenges. Pinewood House Pinewood Place Dartford Kent DA2 7WG

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6. First Aid refresher training is not up to date for all healthcare staff.

Please see below the Trust response to the specific concerns that were raised:

1. Staffing within the Mental Health In-reach team

Recruitment and retention of substantive staff remains a priority for the Trust and following the recruitment of the current mental health operational manager in 2024 the service has seen an increase in recruitment activity as well as retention of staff.

The permanent fill rate within the mental health integrated team between April 2023 and January 2024 was 67% and 79% respectively. The current permanent fill rate of the integrated mental health team is 81%.

The permanent fill rate of the in reach mental health nursing team between April 2023 and January 2024 was 33 % and 67% respectively. The current permanent fill rate of the mental health in reach nursing team is 67% and following a successful recruitment campaign these vacancies are currently being recruited to, and we anticipate a start date to be soon.

Oxleas NHS Foundation Trust are supported with a proactive temporary staffing team, and we endeavour to fill vacant posts within this service with bank or agency staff during the recruitment process. .
4. Communication between prison and healthcare staff The mental health team attend the weekly safety intervention team (SIM Meeting). This is a multi- disciplinary meeting where knowledge regarding concerns of patients with severe and enduring mental health illnesses are shared. The consultant psychiatrist leads a weekly mental health inpatients unit ward round where care plans are discussed and shared with the prison operational staff, this includes discharge planning and those requiring admission to hospital under the mental health act. The mental health operational manager attends the daily prison meeting where prisoners of concerns are raised, those who have self-harmed within the preceding twenty-four hours and those who require constant observations. The integrated mental health team coordinate a weekly new referral meeting, this invitation is open to all prison services. Prison colleagues can attend this meeting to raise concerns and to make referrals. The integrated mental health team hold a weekly case management meeting both IMB and the prison safety team are invited to attend. The role of the safer custody nurse practitioner provides integration between the healthcare team and wider prison team, working closely with colleagues within the safer custody team. The Enhanced Support Service (ESS) was introduced in May 2025 and comprises of a small multi- disciplinary team, including healthcare and prison colleagues who work closely together with a small caseload of the most violent and disruptive prisoners. This care is provided using an individualised, psychologically informed approach.

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The mental health team do not currently make any entries within the NOMIS system for people who are under the mental health caseload however work is in progress to address this and it is anticipated that entries will be made by caseload managers that will ensure that the named case manager and relevant care plans are documented and GDPR guidelines are adhered too.

It is expected that care plans are shared with all relevant personnel.

All members of healthcare are expected to have an activated NOMIS account. Staff with deactivated accounts have been requested to be reinstated. There is no confirmed date for reactivation; however, confirmation has been received that the accounts of those still employed by the Trust have been reactivated. The practice development nurse (PDN) and team leader have been working with staff since the beginning of August, and it is anticipated that all staff will have access to NOMIS and be able to demonstrate this to their line manager before 15 October 2025. A record of this is being maintained and will continue to be monitored. Training and support on the use of NOMIS have been provided to the PDN and will be available to all new users and to existing users where support is required.
6. First Aid refresher training is not up to date for all healthcare staff

Basic life support (BLS) and Intermediate life support (ILS) training is provided to all members of the healthcare team. The current compliance rate for ILS training is 89% and BLS training is 81%. All staff who are currently rostered to provide clinical care on site are up to date with their training compliance.

I hope that this letter reassures you that Oxleas has been highly attentive to the findings of your investigation, and that concerted remedial action has been taken on all the areas you identified to prevent any similar future deaths.

Please do not hesitate to contact me if any clarification or further assurance is required.

Dear Ms Malhotra Thank you for the Regulation 28 report of 18 July 2025 sent to the Secretary of State about the death of Patryk Gladysz. I am replying as the Minister with responsibility for mental health. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Gladysz’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention I have noted the contents of your report, and the matters of concern raised. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns related to healthcare services at HMP Wandsworth. I understand your concerns about staffing shortages within the mental health in-reach team at HMP Wandsworth, and how that may have impacted the quality of mental health assessments. I understand from NHS England that, at the time of Mr Gladysz’s death, the team had a vacancy for one whole time equivalent staff member, and that this has now been filled. In addition, the internal patient safety investigation into Mr Gladysz’s death carried out by Oxleas NHS Foundation Trust, as the healthcare provider at HMP Wandsworth, highlighted wider staff concerns around a lack of supportive leadership at the time of the incident. I am assured by NHS England that these issues have since been addressed, with the appointment in late 2024 of a new operational manager to the prison’s mental health team. Since then, actions have focussed on refreshing and developing the skills of the mental health team in the effective management of referrals, patient triage, and waiting list oversight. The referral process has now been amended and simplified, with training provided to support the wider healthcare team. Other actions taken include a requirement for staff to specifically comment on the need for translation services as part of the patient screening

OFFICIAL-SENSITIVE process and for risks associated with patients on immigration hold or who are awaiting extradition to be recognised. You have also raised concerns around communication between prison and healthcare staff, including a lack of knowledge sharing and a lack of understanding about accessing the NOMIS system. I would agree that appropriate information sharing is essential to support the ongoing care provided to patients in prison settings. I understand that a number of fora have now been set up at HMP Wandsworth to facilitate the sharing of knowledge between prison and healthcare staff about prisoners of concern, including those with complex mental health needs, such as schizophrenia. Action has also been taken to improve understanding around the use of the NOMIS system by healthcare staff. Nationally, all healthcare staff working in prison settings are expected to adhere to the NHS England information sharing position statement issued in 2022. This sets out guidance relating to the sharing of personal health related information held by healthcare staff with other organisations involved in a criminal justice setting and has also been shared with HM Prison and Probation Service. Finally, with regard to your concern that first aid refresher training is not up to date for all healthcare staff, as part of the national service specification for prison healthcare, it is expected for all prison healthcare staff to be trained in basic life support, with annual refresher training included in their mandatory and statutory training plans. At HMP Wandsworth, all healthcare staff undertake Basic Life Support or Immediate Life Support training, dependent on their role. As signatories to the National Partnership Agreement for Health and Social Care for England, the Department of Health and Social Care and NHS England are committed to working with partners to reduce health inequalities for people in prison and improving services to ensure that people have access to timely and effective healthcare whilst in prison. You may be interested to know that the Chief Medical Officer for England intends to publish his report on health in prisons later this year and it is expected that this will provide recommendations for further action across the whole range of prison health services. I understand that Oxleas NHS Foundation Trust will be providing further details in its response to your report about the local actions taken at HMP Wandsworth to address your health-related concerns. I further understand that NHS England (London Region) has received appropriate evidence from the Trust that improvements have been made against the action plans that were developed in response to the death of Mr Gladysz, following the Trust’s internal patient safety and the external investigation by the Prisons and Probation Ombudsman. I would expect your concerns around poor knowledge among prison staff, prison officer checks during roll calls and suicide prevention observations to be addressed by HM Prison and Probation Service and/or the Ministry of Justice in their responses to you. I hope this response is helpful. Thank you for bringing these concerns to my attention.

OFFICIAL-SENSITIVE