Vilhelmas Borkertas
PFD Report
Historic (No Identified Response)
Ref: 2017-0342
Coroner's Concerns (AI summary)
A bisexual prisoner was improperly celled with a homophobic cellmate despite clear risk assessment information, raising concerns about placing inmates with conflicting profiles.
View full coroner's concerns
I gave a great deal of consideration at inquest to the exploration of the time it took staff to attend to Mr Borkertas after his cellmate rang the cell bell. However, I do not write about that now because I know that it is a matter already under scrutiny by the prison, and I do not think there is anything that I can helpfully add.
However, there is another matter that I should like to bring to your attention.
Mr Borkertas described himself variously as heterosexual and bisexual. The latter was recorded on his cell sharing risk assessment form. His cellmate at the time of death described himself as being homophobic. This was recorded on his cell sharing risk assessment form. However, the two were placed together in a cell and I heard no evidence that consideration was ever given to the potential dangers of this.
There is nothing to indicate that this had an impact upon the outcome, but it might be devastating in another case.
However, there is another matter that I should like to bring to your attention.
Mr Borkertas described himself variously as heterosexual and bisexual. The latter was recorded on his cell sharing risk assessment form. His cellmate at the time of death described himself as being homophobic. This was recorded on his cell sharing risk assessment form. However, the two were placed together in a cell and I heard no evidence that consideration was ever given to the potential dangers of this.
There is nothing to indicate that this had an impact upon the outcome, but it might be devastating in another case.
Sent To
- HMP Pentonville
Response Status
Linked responses
0 of 1
56-Day Deadline
26 Dec 2017
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 25 November 2016, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Vilhelmas Borkertas, aged 24 years. The investigation concluded at the end of the inquest on 26 October 2017. The jury made a narrative determination, which I attach.
Circumstances of the Death
Mr Borkertas took his own life on 21 November 2016. His cellmate described waking up in the evening needing to use the toilet, putting on the light and finding Mr Borkertas hanging by a ligature from the window bar.
The cellmate rang the cell bell. It was answered by an operational support grade 21 minutes later. The OSG then called for assistance and Mr Borkertas was cut down when other members of staff arrived. They attempted resuscitation, but this was unsuccessful.
The cellmate rang the cell bell. It was answered by an operational support grade 21 minutes later. The OSG then called for assistance and Mr Borkertas was cut down when other members of staff arrived. They attempted resuscitation, but this was unsuccessful.
Copies Sent To
National Offender Management Service
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Training for IPC professionals engineers and clinicians
Scottish Hospitals Inquiry
Staff training and development
IPC role specifications and staffing levels
Scottish Hospitals Inquiry
Staff training and development
Balancing vulnerability with professional curiosity
Southport Inquiry
Staff training and development
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.