Marcin Mazurek
PFD Report
Historic (No Identified Response)
Ref: 2017-0282
Coroner's Concerns (AI summary)
Medical record keeping was of very poor quality, and daily or tri-weekly medical checks in segregation were often not recorded or did not occur.
View full coroner's concerns
(1) Medical record keeping was of very poor quality (2) The daily medical checks in segregation by members of the nursing team and the tri-weekly checks by the GP team, were frequently not recorded in the medical notes and / or did not take place.
Sent To
- NHS England
Response Status
Linked responses
0 of 1
56-Day Deadline
22 Jan 2018
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 7th September 2015 an investigation was commenced into the death of Marcin Miroslaw Mazurek aged 32. The investigation concluded at the end of the inquest on 4th October 2017. The conclusion of the inquest was that the deceased had died by hanging. The jury further found that the deceased had spent an inappropriately long time in segregation, that there had been a failure in the proper implementation of ACCT procedures, with no multidisciplinary working and no involvement of mental health and inadequate reporting by discipline and medical teams.
Circumstances of the Death
The deceased had become mentally unwell which condition was exacerbated by a very long period in segregation. He began to self-harm and ultimately hanged himself.
Action Should Be Taken
The medical notes of prisoners are often of a poor quality, particularly in the realms of mental health. Although it is the professional responsibility of doctors and nurses to make adequate entries in the medical records of prisoners, nevertheless you might wish to consider a universal system of training and audit across the prison estate in relation to medical note recording.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.