Igor Vujkovic

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Igor Vujkovic,
a prisoner at HMP Maidstone,
on 11 May 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Igor Vujkovic died of epilepsy on 11 May 2024 at HMP Maidstone. He was 25 years
old. I offer my condolences to Mr Vujkovic’s family and friends.
The clinical reviewer concluded that the care Mr Vujkovic received at Maidstone was not
equivalent to that which he could have expected to receive in the community. Although Mr
Vujkovic told staff when he arrived that he had epilepsy, he was not referred to a GP nor
was a care plan put in place.
Some prison staff were unaware that Mr Vujkovic had epilepsy. This potentially led to a
delay in them realising that he had had a seizure when they saw him on the floor of his
cell. Maidstone should improve information sharing between healthcare and prison staff so
that wing staff are aware of prisoners with potentially life-threatening medical conditions.
Mr Vujkovic was in a single cell so no one was able to raise the alarm when he had a
seizure. I am aware that some prisons consider it best practice to provide a shared cell to
prisoners with epilepsy but this was not the case at Maidstone. I recommend that there is a
regional policy on cell sharing for prisoners with epilepsy, which could help save lives.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman January 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 17 February 2023, Mr Igor Vujkovic was sentenced to five years and six months
in prison for drug offences. On 17 April, he was moved to HMP Maidstone.
2. When he arrived at Maidstone, Mr Vujkovic told the reception nurse that he had
epilepsy. He said he did not take medication and managed it in the community by
using cannabis.
3. Mr Vujkovic was initially allocated a shared cell but was later moved to a single cell.
4. On 19 December, Mr Vujkovic saw a GP at Maidstone and said he had had three
seizures in less than 20 days. Mr Vujkovic said he was not keen on taking
anticonvulsants, so the GP prescribed an antidepressant to manage his stress levels.
5. Between 29 December and 29 March 2024, Mr Vujkovic did not collect his
medication. He did not report any more seizures.
6. At approximately 6.50am on 11 May, during a routine check, an officer saw Mr
Vujkovic lying on the floor of his cell. As she could not see Mr Vujkovic properly, the
officer asked her colleague to also look through the observation panel. The second
officer thought he could see Mr Vujkovic breathing so they both continued with their
checks. When asked at interview whether they knew Mr Vujkovic had epilepsy, one
said they did and the other said that staff on the wing did not know.
7. At approximately 8.49am, an officer opened Mr Vujkovic’s cell and saw him lying on
the floor. He called his name but Mr Vujkovic did not respond. The officer called a
medical emergency code.
8. The prison called an ambulance while officers and healthcare staff tried to resuscitate
Mr Vujkovic.
9. Paramedics arrived at approximately 9.08am. They assessed that Mr Vujkovic had
been dead for some time and at 9.10am, declared him deceased.
10. The post-mortem found that the cause of Mr Vujkovic’s death was sudden death in
epilepsy.
Findings
11. The clinical reviewer concluded that Mr Vujkovic’s care was not equivalent to that
which he could have expected to receive in the community. Despite Mr Vujkovic
telling the reception nurse when he arrived at Maidstone that he had epilepsy, he
was not referred to a GP and no care plan was created for him. When Mr Vujkovic
failed to collect his antidepressant medication multiple times, there was no follow-up
or review.
12. Prison staff gave varying accounts of whether they knew Mr Vujkovic had epilepsy
and how they had been informed. There did not appear to be a clear, well-
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
understood process for healthcare staff to share information with prison staff about
prisoners with serious, life-threatening conditions such as epilepsy.
13. We are aware that in some prisons, cell sharing is advised for prisoners with
epilepsy. The Head of Healthcare at Maidstone told us at interview that he did not
agree with this as he considered it unreasonable to expect a cellmate to be
responsible for another prisoner’s care. We consider that there should be a
consistent position on the appropriateness of recommending shared cells for
prisoners with epilepsy. While there may be circumstances in which it would be
inappropriate to expect a prisoner to share, it is also the case that a prisoner having a
seizure is unlikely to be able to raise the alarm whereas a cellmate could, which
could save a life.
Recommendations
• The Head of Healthcare should ensure that prisoners with epilepsy are referred to a
doctor, placed on a long-term care pathway and have a care plan.
• The Head of Healthcare should establish a system for medication reviews with
prisoners who fail to collect their medication on several occasions.
• The Governor and Head of Healthcare should review their information sharing
protocol for prisoners with serious medical conditions such as epilepsy.
• The Commissioner for Health and Justice NHS England South East should work
collaboratively with commissioned healthcare providers in custodial settings to
formulate a regional approach and implement a process on when to recommend cell
sharing for prisoners with life-threatening long-term conditions such as epilepsy.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
14. HMPPS notified us of Mr Vujkovic’s death on 11 May 2024.
15. The investigator issued notices to staff and prisoners at HMP Maidstone informing
them of the investigation and asking anyone with relevant information to contact her.
No one responded.
16. The investigator obtained copies of relevant extracts from Mr Vujkovic’s prison and
medical records.
17. The investigator interviewed three members of staff at Maidstone on 1 July. She
interviewed two further members of staff on 5 and 16 July by video call.
18. NHS England commissioned an independent clinical reviewer to review Mr Vujkovic’s
clinical care at the prison. She conducted joint interviews with the investigator on 1
and 5 July.
19. We informed HM Coroner for Kent and Medway of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
20. The Ombudsman’s office contacted Mr Vujkovic’s sister and his friend to explain the
investigation and to ask if they had any matters they wanted us to consider. They did
not respond.
21. We shared our initial report with HMPPS and the prison’s healthcare provider, Oxleas
NHS Foundation Trust. They found no factual inaccuracies. They provided an action
plan which is annexed to this report. We agreed to an amendment to the fourth
recommendation which is reflected in this report.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Maidstone
22. HMP Maidstone is a category C prison in the southeast of England. It holds foreign
national offenders in a mixture of single and double cells. Oxleas NHS Foundation
Trust provides healthcare services.
HM Inspectorate of Prisons
23. The last full inspection of Maidstone was in October 2022. Inspectors reported that
many aspects of health care services were reasonably good and clinics were running
well with relatively low non-attendance rates. Improvement had been made to the
management of patients with long-term conditions. Regular clinics were held and
staff had received additional training. Patients had care plans, most of which were
individualised and appropriate for the patient’s need.
Independent Monitoring Board
24. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and decently.
In its latest annual report, for the year to 28 February 2023, the IMB reported that
overall Maidstone was a safe prison. They found the prison was well run, prisoners,
for the most part enjoyed a good relationship with staff and each other and violence
continued to remain low. They found that Oxleas NHS Foundation Trust provided
individualised care plans and regular clinics for prisoners with long-term conditions.
Previous deaths at HMP Maidstone
25. Mr Vujkovic was the fourth prisoner to die at Maidstone since May 2021. There are
no similarities between the findings in our investigation into Mr Vujkovic’s death and
the findings from our investigations into the previous deaths.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
26. On 17 February 2023, Mr Igor Vujkovic, a Croatian national, was sentenced to five
years and six months in prison for drug offences. On 17 April, Mr Vujkovic was
moved to HMP Maidstone.
27. During his reception health screen, Mr Vujkovic told the reception nurse that he had
epilepsy and that he managed it in the community by using cannabis. He said he was
not prescribed medication and that his last seizure had been over three months
before. Mr Vujkovic gave consent for his medical information to be shared. The
reception nurse did not refer him to a GP to discuss his epilepsy or place him on a
long-term care pathway.
28. Mr Vujkovic was assessed as standard risk for cell sharing. He was initially located in
a shared cell on Weald Wing but on 3 November, he was moved to a single cell on
Thanet Wing.
29. Mr Vujkovic saw a GP on 19 December and said that as he no longer had access to
cannabis, he had had three seizures in less than 20 days. Mr Vujkovic said they were
due to stress and they usually happened at night. He said he was not keen on taking
anticonvulsants, so the GP prescribed mirtazapine (an antidepressant used to treat
symptoms of depression and anxiety) to manage his stress. The GP made no further
plans for Mr Vujkovic’s care to be reviewed.
30. Between 29 December and 29 March 2024, Mr Vujkovic did not collect his
medication. There is no evidence from the medical records that staff followed up with
Mr Vujkovic.
31. Mr Vujkovic was due to be deported to Croatia on 20 May. Healthcare staff produced
an epilepsy care plan on 25 April and shared it with the prison operations and
removals team. The care plan said that Mr Vujkovic had last had a seizure over a
month before and healthcare staff should be informed of all seizures. There is no
evidence in the records that healthcare staff were informed of any further seizures.
Events of 11 May
32. At approximately 6.50am on 11 May, during the morning roll check, Officer A looked
through the observation panel into Mr Vujkovic’s cell and saw him lying on the floor.
She saw he was lying with his head underneath the sink area and his feet pointing
towards the door. Officer A thought she could see Mr Vujkovic breathing but found it
difficult to see properly because of his position in the cell.
33. Officer B was nearby so Officer A asked him to come over and double-check on Mr
Vujkovic. When Officer B looked through the observation panel, he thought he could
see Mr Vujkovic breathing. Both officers then continued with the roll check.
34. During interview, Officer B said that he and Officer A had both tried to get a verbal
response from Mr Vujkovic but had been unsuccessful. In contrast, when
interviewed, Officer A said that neither she nor Officer B tried to get a verbal
response from Mr Vujkovic. Officer B told the investigator that he was aware that Mr
Vujkovic had epilepsy because his name and condition were listed in the wing office,
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
on the list of prisoners with PEEPs (Personal Emergency Evacuation Plans - for a
person who may need assistance to evacuate a building or reach a place of safety in
the event of an emergency). Officer A said that she was unaware that Mr Vujkovic
had epilepsy and that Mr Vujkovic was not listed on the PEEP board. As far she was
aware, no staff on the wing were aware that Mr Vujkovic had epilepsy.
35. Officer C was responsible for unlocking prisoners’ cells on Mr Vujkovic’s wing that
morning. When he unlocked Mr Vujkovic’s cell at approximately 8.49am, he saw him
lying on the floor. He called his name but Mr Vujkovic did not respond. He called the
Supervising Officer (SO) over, who immediately entered the cell.
36. The SO called Mr Vujkovic’s name several times but did not get a response. He
instructed Officer C to call a code blue (a medical emergency code used when a
prisoner is unconscious or having breathing difficulties that alerts healthcare staff and
prompts the control room to call an ambulance immediately). In interview, the SO
said that he was aware that Mr Vujkovic had epilepsy because of a conversation they
had when he was on Weald Wing.
37. The control room called 999 but they were unable to provide the call handler with the
required information, such as whether the patient was breathing. The control room
put the call handler through to the wing staff who were then able to provide the
information required. This delayed the ambulance being dispatched by around four
minutes.
38. The SO continued to call Mr Vujkovic’s name and approximately one minute after the
code blue was called other prison staff arrived. They turned Mr Vujkovic onto his
back, checked for signs of life and started CPR. In his statement, the SO described
Mr Vujkovic’s body as showing signs of rigor mortis and hypostasis (blood pooling).
(These changes take place around two hours after death).
39. Healthcare staff arrived promptly and continued CPR. They also commented that
there were physical signs that Mr Vujkovic was dead.
40. Paramedics arrived at approximately 9.08am and declared Mr Vujkovic deceased at
9.10am.
Contact with Mr Vujkovic’s family
41. On 11 May, the prison appointed a family liaison officer (FLO).
42. The FLO called Mr Vujkovic’s next of kin, his mother, in Croatia at 12.10pm to inform
her of his death. At Mr Vujkovic’s mother’s request, the FLO then called Mr Vujkovic’s
friend who was in the UK.
43. Later that day, the FLO spoke to Mr Vujkovic’s family again and it was agreed that Mr
Vujkovic’s sister would be the main point of contact between the prison and the
family.
44. The prison contributed financially to Mr Vujkovic’s funeral in line with national
guidance.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
45. The FLO liaised with Mr Vujkovic’s friend about returning Mr Vujkovic’s belongings to
his family.
Support for prisoners and staff
46. After Mr Vujkovic’s death, a debrief was held for the staff involved in the emergency
response to ensure they had the opportunity to discuss any issues arising and to
offer support. Five of the prison officers involved were sent home for the rest of the
day.
47. The chaplain visited prisoners who were friends of Mr Vujkovic to tell them of his
death and to offer support.
Post-mortem report
48. The post-mortem report concluded that Mr Vujkovic’s cause of death was sudden
death in epilepsy.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Clinical care
49. The clinical reviewer concluded that Mr Vujkovic’s care was not equivalent to that
which he could have expected to receive in the community.
50. Despite Mr Vujkovic telling the reception nurse when he arrived at Maidstone that he
had epilepsy, he was not referred to a GP, was not placed on a long-term condition
pathway and a care plan was not created to support the management of his epilepsy.
He saw the GP at Maidstone eight months later, reporting an increase in seizures.
The GP also did not take steps to support the management of Mr Vujkovic’s
condition. We recommend:
The Head of Healthcare should ensure that prisoners with epilepsy are referred
to a GP, placed on a long-term condition pathway and have a care plan.
51. Mr Vujkovic was prescribed medication to help manage his stress levels after he
reported having three seizures at night. However, when he failed to collect his
medication multiple times, there was no follow-up or review. We recommend:
The Head of Healthcare should establish a system for medication reviews with
prisoners who fail to collect their medication on several occasions.
Management of prisoners with epilepsy
Information sharing
52. We consider that prison staff should be made aware of prisoners who have a serious,
potentially life-threatening medical condition, such as epilepsy, and particularly so if it
is poorly controlled. Prison staff would then be more alert to changes in the prisoner’s
behaviour and more likely to carry out a welfare check or ask healthcare staff to
check on them if there was any cause for concern. At his healthcare reception
screening, Mr Vujkovic gave consent for his medical information to be shared so
there was no reason why prison staff should not have been made aware of his
epilepsy. However, prison staff gave varying accounts of whether they knew Mr
Vujkovic had epilepsy and how they had been informed.
53. The SO said he knew from a conversation he had had with Mr Vujkovic on a previous
wing. Officer B said he knew from the PEEP board, though it was disputed by Officer
A that Mr Vujkovic was listed. Our understanding of the purpose of a PEEP, a plan to
assist individuals who may have difficulties evacuating a building in an emergency,
would not ordinarily apply to a prisoner with epilepsy and in our view, would seem an
ineffective way of notifying wing staff of prisoners with serious, potentially life-
threatening medical conditions. It appears that there was not a clear, well-understood
process for healthcare staff to share information about prisoners with serious medical
conditions with prison staff.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
54. We recommend:
The Governor and Head of Healthcare should review their information sharing
protocol for prisoners with serious medical conditions such as epilepsy.
Cell sharing
55. We are aware that in some prisons, it is considered best practice to give prisoners
with epilepsy a shared cell so that during periods when prisoners are locked in their
cell, their cellmate can raise the alarm if necessary. When we asked the Head of
Healthcare at Maidstone about the possibility of prisoners with epilepsy being
allocated a cellmate, he said it would not be appropriate to ask another prisoner to
take responsibility for someone else’s care.
56. We consider that there should be guidance, at a regional level, about best practice
for managing prisoners with life-threatening long-term conditions such as epilepsy,
including the appropriateness of cell sharing. We recommend:
The Commissioner for Health and Justice NHS England South East should
work collaboratively with commissioned healthcare providers in custodial
settings to formulate a regional approach and implement a process on when to
recommend cell sharing for prisoners with life-threatening long-term
conditions such as epilepsy.
Governor to note
Delay in checking on Mr Vujkovic’s welfare
57. We consider that Officer A and Officer B should have entered Mr Vujkovic’s cell to
check on him when they carried out the 6.50am roll check. We are aware that a roll
check is primarily a count of prisoners and not a welfare check, so a verbal response
is not normally needed. However, if the staff member notices anything untoward, they
should satisfy themselves that there are no concerns about the prisoner’s welfare.
We would expect them to try to get a verbal response from the prisoner in those
circumstances and in the absence of a verbal response, to go into the cell to check
on the prisoner.
58. Officer A said that neither she nor Officer B tried to get a response from Mr Vujkovic.
Officer B said they did but that Mr Vujkovic did not respond. They should have gone
into the cell at this point to check on Mr Vujkovic. Even if they thought they saw him
breathing, his position on the floor of his cell and lack of response should have
prompted the officers to go into the cell. We cannot say if it would have made any
difference to the outcome as there is a strong possibility that Mr Vujkovic was already
dead at 6.50am, but we bring this issue to the Governor’s attention.
Emergency response
59. There was a delay in the ambulance being despatched to the prison as when control
room staff called for the ambulance, they were unable to answer the standard
question, “Is the patient breathing?”. They put the call through to Thanet Wing
instead, which caused a four-minute delay. It made no difference to the outcome for
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Mr Vujkovic as he was dead when found, but we bring this to the Governor’s
attention.
60. We are aware of ongoing work, commissioned by the Director General of HMPPS
and in collaboration with health partners, to ensure that those responsible for calling
an ambulance have sufficient information to do so without delay and to give accurate
information about the condition of the patient.
Inquest
61. At the inquest, held from 24 February to 4 March 2025, the jury concluded that Mr
Vujkovic died from natural causes, due to sudden unexpected death in epilepsy.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE