Liridon Saliuka

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Liridon Saliuka,
a prisoner at HMP Belmarsh,
on 2 January 2020
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
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© Crown copyright, 2025
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Liridon Saliuka was found hanged in his cell at HMP Belmarsh on 2 January 2020. He
was 29 years old. I offer my condolences to Mr Saliuka’s family and friends.
Mr Saliuka was upset and angry that he had been moved out of an adapted cell (for those
with a disability) into a standard cell two days before his death. I am satisfied that the
move was not unreasonable or inappropriate although I consider it could have been
handled better.
Staff had restrained Mr Saliuka on the morning of his death. I am satisfied that the use of
force was justifiable, and that, although Mr Saliuka suffered some superficial injuries, these
did not contribute to his death.
I am also satisfied that prison staff could not have foreseen Mr Saliuka’s actions later that
day. However, I am concerned that houseblock staff did not know that Mr Saliuka’s trial
had been due to start on 6 January, and that he did not have regular sessions with a key
worker. These may have been missed opportunities to identify that he might be at risk.
The clinical reviewer found that the physical and mental healthcare that Mr Saliuka
received was equivalent to that which he could have expected to receive in the community.
I am, however, concerned that there were delays before he was seen by a psychiatrist and
a psychological therapist. I am also concerned that, although the psychological therapist
assessed that Mr Saliuka had severe depression, severe anxiety disorder and severe
psychological distress on 3 December, she did not consider starting Prison Service suicide
prevention measures (known as ACCT) and did not take any other immediate action to
provide Mr Saliuka with support.
I am also concerned that there was a delay in breaking the news of Mr Saliuka’s death to
his family.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman August 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 5
Background Information ................................................................................................... 7
Key Events ....................................................................................................................... 9
Findings ......................................................................................................................... 18
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Summary
Events
1. On 17 July 2019, Mr Liridon Saliuka was remanded in prison custody on suspicion
of murder and possession of a firearm. After three days at HMP Thameside, Mr
Saliuka was moved to HMP Belmarsh.
2. In January 2018, Mr Saliuka had been involved in a car accident and had suffered
numerous injuries, including fractures to his back, leg, foot and face. He met the
definition of disabled under the Equalities Act. While at Belmarsh, Mr Saliuka
regularly saw different prison GPs about his injuries and, after the completion of a
social care action plan, a prisoner was appointed as a care and support orderly to
clean his cell and help with other activities.
3. On 23 August, Mr Saliuka was moved to an adapted cell (for those with a disability),
although this does not appear to have been authorised by a GP.
4. Between 22 August and 23 September, a mental health nurse saw Mr Saliuka on
four occasions. The nurse wanted Mr Saliuka to see a psychiatrist and have a
psychological assessment but discharged him before these appointments took
place.
5. On 4 November, a psychiatrist saw Mr Saliuka. Mr Saliuka said that he had a long
history of trauma and was desperate to talk about it, so the psychiatrist referred him
for a psychological assessment.
6. On 3 December, a specialist psychological therapist assessed Mr Saliuka and
concluded that he had severe depression, severe anxiety disorder and severe
psychological distress. She planned to see him for one-to-one cognitive behaviour
therapy (CBT), starting in early January 2020.
7. On 27 December, Mr Saliuka refused an order to move from the adapted cell.
8. On 30 December, Mr Saliuka’s sister telephoned the prison and left a message to
say she was concerned that Mr Saliuka had not telephoned his family for a few
days. No one responded to her message.
9. On 31 December, Mr Saliuka agreed to be moved, though he complained about this
to a prison GP. He called his family the same day.
10. On the morning of 2 January, Mr Saliuka threatened his care and support orderly,
forced his way out of his cell and was restrained by prison staff.
11. At approximately 5.25pm, staff delivered the evening meal to Mr Saliuka in his cell,
but they could not see him and he did not respond to their calls. After an officer
obtained a torch, a Supervising Officer looked into the cell and thought that he could
see Mr Saliuka hanging. After seeking advice from a custodial manager, officers
entered Mr Saliuka’s cell and found him hanging from a ligature at the back of the
cell. At 5.46pm, an officer called a code blue emergency (which indicates that a
prisoner is unconscious or having difficulty breathing) and others started
cardiopulmonary resuscitation (CPR).
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12. A prison GP, other healthcare staff and paramedics continued CPR but they were
unable to resuscitate Mr Saliuka and, at 6.32pm, the GP declared that he had died.
Findings
13. We are satisfied that it was reasonable for staff to have restrained Mr Saliuka on the
morning of his death, and that he received superficial injuries that did not contribute
to his death.
Assessment of Mr Saliuka’s risk of suicide and self-harm
14. While Mr Saliuka had some risk factors that increased his risk of suicide and self-
harm, prison staff were not aware that he had mental health issues, and he had not
tried to take his life or told anyone that he had thought about it. We are satisfied that
prison staff could not have foreseen Mr Saliuka’s actions.
15. We do, however, consider that information about his forthcoming trial should have
been shared with houseblock staff.
The adapted cell
16. As a Category A prisoner, Mr Saliuka was required to move cells every few months.
We have found no evidence that a doctor had said that Mr Saliuka required an
adapted cell for medical reasons. Staff checked this before they asked him to move
in December 2019. We are, therefore, satisfied that there was no reason why Mr
Saliuka should not have been moved to a standard cell. However, we question the
timing of the move, which took place before a scheduled meeting between prison
and healthcare staff to discuss Mr Saliuka’s specific needs had taken place.
Key worker scheme
17. We are disappointed that Mr Saliuka was not allocated a key worker for most of his
time at Belmarsh. This was a possible missed opportunity to provide him with
support.
The Safer Custody hotline
18. We are concerned that on 31 December, the prison overlooked a message from Mr
Saliuka’s sister, left on the Safer Custody hotline, where she raised concerns about
her brother.
Physical health provision
19. The clinical reviewer was satisfied that the physical care that Mr Saliuka received
was equivalent to that which he could have expected to receive in the community.
Healthcare staff considered his physical health in detail and he received consistent
and reliable support from the social care team.
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Mental health and psychology provision
20. The clinical reviewer was satisfied that the mental health care that Mr Saliuka
received was equivalent to that which he could have expected to receive in the
community.
21. We are, however, concerned at the delays before he was seen by the forensic
psychiatrist and the psychological therapist.
22. We are also concerned that although the psychological therapist assessed Mr
Saliuka as suffering from severe depression, severe anxiety disorder and severe
psychological distress on 3 December, she did not consider opening an ACCT or
take any other immediate action to provide him with support.
Emergency response
23. We are concerned that there was a delay in entering Mr Saliuka’s cell when officers
thought he was hanging; that there was a delay before a medical emergency code
was called; and that prison and healthcare staff attempted resuscitation when Mr
Saliuka displayed rigor mortis.
24. We are also concerned that our investigation was hampered by the lack of
operational CCTV cameras on Houseblock 4.
Family liaison
25. We are concerned that there was a five-hour delay between Mr Saliuka’s death and
a family liaison officer breaking the news to his family.
Follow up care for prisoners
26. We are concerned that prison staff offered limited support to friends of Mr Saliuka,
who had been directly affected by his death.
Recommendations
• The Governor should ensure that staff understand the need to record and share
relevant information that may affect a prisoner’s risk.
• The Governor and Head of Healthcare should ensure that where a prisoner requires
special accommodation or equipment for medical or social care reasons, this is
formally authorised and recorded.
• The Governor should ensure that prisoners are promptly allocated a key worker,
who is able to see them on a regular basis.
• The Governor should ensure that staff regularly check and respond promptly to
messages left on the Safer Custody hotline.
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• The Head of Healthcare should ensure that psychiatric and psychological
assessments:
• take place within a specific timeframe; and
• are not cancelled unless there are justified and documented reasons.
• The Head of Healthcare should ensure that all staff:
• are aware of their responsibility to open an ACCT if they have concerns that a
prisoner may be at risk of suicide or self-harm; and
• understand that they need to consider a prisoner’s risk factors when assessing
his risk of suicide or self-harm, and not focus solely on what the prisoner says
about his intentions or how he presents.
• The Head of Healthcare should share this report with the specialist psychological
therapist and discuss the Ombudsman’s findings with her.
• The Governor should ensure that staff call a medical emergency code as soon as
possible if a prisoner appears to be hanging.
• The Governor should share a copy of this report with Supervising Officer A and
ensure that a senior manager discusses the Ombudsman’s findings with him.
• The Governor should ensure that the CCTV cameras on Houseblock 4 are
reactivated or replaced as a matter of urgency.
• The Governor and Head of Healthcare should ensure that staff are given guidance
about the circumstances in which resuscitation is inappropriate, in accordance with
European Resuscitation Council Guidelines.
• The Head of Healthcare should share a copy of this report with GP A and provide
him and the prison’s other GPs with a copy of the resuscitation guidance.
• The Governor should ensure that a family liaison officer breaks the news of a death
to a next of kin in person as soon as possible, in line with PSI 64/2011.
• The Governor should ensure that the Prisons and Probation Ombudsman is
promptly provided with all requested documents following a death in custody, in line
with PSI 58/2010.
• The Governor should ensure that after a prisoner dies, prisoners who were close to
him are informed of the death personally and offered appropriate, individual
support.
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The Investigation Process
27. The investigator issued notices to staff and prisoners at HMP Belmarsh informing
them of the investigation and asking anyone with relevant information to contact
him. One prisoner responded.
28. The investigator visited Belmarsh on 9 January 2020. He obtained copies of
relevant extracts from Mr Saliuka’s prison and medical records.
29. NHS England commissioned an independent clinical reviewer to review Mr
Saliuka’s clinical care at the prison.
30. The investigator interviewed 19 members of staff at Belmarsh on 1, 4, 13, 14 and
15 May, and 18 and 19 June. The clinical reviewer joined the investigator for four
interviews on 14 May and 18 June. All the interviews were conducted by telephone
due to the restrictions in place because of the COVID-19 pandemic.
31. The investigator wrote to six prisoners asking if they were wiling to be interviewed.
One did not reply, one had died in the community after being released, and two
refused (although we understand one wrote to the coroner and asked to provide a
statement to solicitors representing Mr Saliuka’s family). Two agreed and the
investigator interviewed one at HMP Swaleside on 9 April and one at HMYOI
Aylesbury on 22 May.
32. We informed HM Coroner for Inner South London District of the investigation. He
gave us the results of the post-mortem examination. We have sent the coroner a
copy of this report.
33. One of the Ombudsman’s family liaison officers contacted Mr Saliuka’s father to
explain the investigation and to ask if he had any matters he wanted the
investigation to consider. Mr Saliuka’s sister became the family’s point of contact.
She said that the family had been told by other prisoners that Mr Saliuka had been
beaten or strangled by prison officers who had then made his death look like
suicide. She also asked the following questions:
• Why was the safer custody line not manned and why did staff not know how
to access voicemails?
• Why was Mr Saliuka not allowed to stay in the adapted cell?
• When was the second altercation and why did the prison not inform the
Coroner about the second altercation?
• Did Mr Saliuka have lunch or dinner on 2 January 2020?
• Were there any plans to take Mr Saliuka to the segregation unit after the first
incident and were ‘G4S’ (or a special team) called in to do this?
• Are there any plans to install CCTV on Houseblock 4 and, if not, why not?
We have addressed these questions in this report.
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34. We shared our initial report with HM Prison and Probation Service (HMPPS). They
pointed out some minor factual inaccuracies which have been amended in this
report. They provided an action plan which is annexed to this report.
35. We sent a copy of our initial report to the solicitor representing Mr Saliuka’s family.
They pointed out some factual inaccuracies which were amended in the final report.
36. We issued our final report in November 2023. Mr Saliuka’s family made
representations that the findings made in our report did not align with the findings
made at the inquest and asked us to review our investigation. Following a review,
we have made further changes to our final report which we have reissued.
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Background Information
HMP Belmarsh
37. HMP Belmarsh is a high security and local prison serving the Central Criminal Court
and the courts of South East London and South West Essex. It holds approximately
900 men. Oxleas NHS Foundation Trust provides healthcare services. There is 24-
hour healthcare cover and a 32-bed inpatient unit.
HM Inspectorate of Prisons
38. The most recent inspection of HMP Belmarsh was a short scrutiny visit to the long-
term and high security estate on 26 May 2020. Inspectors reported that the number
of self-harm incidents remained stable and that case management for prisoners at
risk of suicide or self-harm was still being undertaken in line with requirements.
39. The most recent full inspection of Belmarsh was in January and February 2018.
Inspectors reported that rates of self-harm were not high, though the quality of
ACCTs varied. Some ACCT assessments were excellent and reviews took place
regularly with good input from the mental health team.
40. Inspectors found that primary healthcare services were comprehensive, which
included the ability to see GPs on the same day for urgent matters, though non-
attendance rates were too high. They found that mental health services had
improved and the support for prisoners with mild to moderate and enduring mental
health problems was good. They also found that the psychologically-led service
offered a good range of self-help material, group work and individual therapies for
prisoners with mild to moderate problems. Inspectors found that social care
provision was exemplary.
Independent Monitoring Board
41. 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 30 June 2019, the IMB reported
that board members continued to randomly quality-check ACCT entries and found
most were acceptable.
42. The IMB reported that non-attendance by prisoners at healthcare appointments
remained a concern and that there had been occasional friction between nursing
staff and prison officers when dispensing medication. They also were concerned
with staffing at night as only one nurse was on duty.
Previous deaths at HMP Belmarsh
43. Mr Saliuka was the seventh prisoner to die at Belmarsh since January 2018. Two of
the previous deaths were self-inflicted and four were from natural causes. There
have been five deaths since, one self-inflicted, three from natural causes and one
homicide. We have previously made recommendations about the key worker
scheme (in May 2020) and about family liaison (in August 2020).
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Assessment, Care in Custody and Teamwork (ACCT)
44. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and support the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multi-disciplinary review meetings involving the prisoner. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011,
Management of prisoners at risk of harm to self, to others and from others (Safer
Custody).
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Key Events
45. In January 2018, Mr Liridon Saliuka was involved in a car accident in the community
and suffered numerous injuries, including fractures to his back, leg, foot and face.
He spent ten days in intensive care, underwent surgery on his face, back, leg and
ankle, and was wheelchair bound for three months.
46. On 17 July 2019, Mr Saliuka was remanded in prison custody on suspicion of
murder and possession of a firearm and sent to HMP Thameside. This was not his
first time in prison.
47. On 20 July, Mr Saliuka was moved to HMP Belmarsh. The nurse who conducted his
initial health assessment recorded that he displayed “exaggerated crying and
behaviour in order to convince me to place him in Inpatients due to chronic pain and
old injuries”. She noted that Mr Saliuka was fit for normal location, work and any cell
occupancy. She referred him to a prison GP.
48. Later that day, a prison GP saw Mr Saliuka, who said that he had many broken
bones and felt like “a wreck”. The GP noted that Mr Saliuka was able to walk
unaided without pain and considered he did not need to be located in the prison’s
inpatient unit.
49. On 22 July, the health and wellbeing coordinator saw Mr Saliuka, who said that he
had not had any contact with mental health services in the community, though he
felt he was struggling to cope mentally. The health and wellbeing coordinator noted
that Mr Saliuka was tearful so she referred him to the primary care mental health
team.
50. Later that day, a prison GP saw Mr Saliuka, who asked for an extra mattress and
pillow. The GP agreed to authorise this, referred him to the physiotherapist and
prescribed him sertraline (for anxiety).
51. On 25 July, prison GP A saw Mr Saliuka, who said that he had pain in his lower
back, thigh and ankle. GP A examined Mr Saliuka and found that his lumbar
muscles were tight. He referred Mr Saliuka to the social care team, the remedial
gym and the physiotherapist. (Mr Saliuka was initially discharged from
physiotherapy, after he did not attend the appointments on 8 and 29 August, but
then the physiotherapist saw him on 10 September and 17 October.)
52. Four days later, a Care, Grow, Live (CGL) project manager completed a social care
referral to the Royal Borough of Greenwich (RBG) and asked them to assess Mr
Saliuka for support. (CGL is a charity commissioned to provide social care and
other advice to prisoners in some prisons.) She wrote that Mr Saliuka had been in a
car accident and that he complained of pain and being unable to sleep due to
having a hard bed and chair.
53. On 31 July, an RBG case management assistant and an RBG occupational
therapist saw Mr Saliuka to assess his social care needs and to produce an interim
support plan. Mr Saliuka said that he walked without walking aids, though he had a
left sided limp; that he was always in pain; and that he had been diagnosed with
depression. The RBG case management assistant and occupational therapist
recommended that the mental health team see Mr Saliuka about his depression,
that the GP see him about being provided with a different mattress and chair, that
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the physiotherapist see him about going to the remedial gym to exercise, and that a
care and support orderly should support him with cleaning his cell and doing his
laundry.
54. The same day, a GP saw Mr Saliuka, who said that he wanted to change his
mattress. The GP agreed to this but said that Mr Saliuka would have to give up his
current mattress. The GP also diagnosed Mr Saliuka with a mixed anxiety and
depressive disorder.
55. On 5 August, a prison GP saw Mr Saliuka, who said that he had aches and pains
after his multiple injuries. He recorded that Mr Saliuka wanted lots of “stuff”, though
this is not defined, and that he could not complete an F35 (a form that allows a
doctor to authorise certain requirements for prisoners based on their medical
problems) for all that was requested. There is no record that the GP completed an
F35.
56. From 6 August, CGL social care support workers saw Mr Saliuka regularly to check
on him and his care and support orderly.
57. On 22 August, a nurse saw Mr Saliuka for a primary care mental health review. Mr
Saliuka said that he felt hopeless in prison, traumatised by the car accident and that
his mood was low. He said he had no thoughts of suicide or self-harm. The nurse
noted that Mr Saliuka maintained eye contact and his concentration, though he
spoke excessively and appeared restless. She kept him on the primary care mental
health team caseload and noted that a forensic psychiatrist was due to see him on
9 September. There is no record that this appointment took place.
58. The following day, staff moved Mr Saliuka to an adapted cell on Houseblock 4.
Supervising Officer (SO) A said that Mr Saliuka was initially put in the cell “purely by
coincidence” because it was the only cell available. A CGL care coordinator noted
in Mr Saliuka’s electronic social care notes that he was moved there as there was a
care and support orderly available to support him. (It is not clear if by ‘there’ she
meant the adapted cell or Houseblock 4.)
59. On 27 August, a nurse tried to see Mr Saliuka but could not because he had moved
to a new houseblock (Houseblock 4). She noted in Mr Saliuka’s electronic medical
record that he was moved as he “allegedly reported that his mobility problems got
worse”. We do not know who provided her with this information.
60. The following day, the nurse reviewed Mr Saliuka, who said he thought that prison
staff assumed that he was lying about his injuries and mobility because he went to
the gym. He also thought that he was taking sertraline (an antidepressant) for his
physical injuries but did not want a prison GP to review his medication. The nurse
referred Mr Saliuka to psychology to explore his trauma following his accident and
noted that the psychiatrist was due to see him on 7 October. There is no record that
this appointment took place or why the date had changed.
61. On 13 September, a social care review was carried out. Mr Saliuka expressed
concern that the care and support orderly was not coming to the cell, but the social
work team established that this was not the case and that the orderly was attending
twice a week as described in the care plan.
62. On 18 September, the nurse reviewed Mr Saliuka, who said that he was doing well
and thought he had a strong defence for his murder trial. He said that he did not
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want a prison GP to increase his sertraline dose because it worked well. The nurse
said that he would shortly be discharged from the primary care mental health team,
though Mr Saliuka did not want this as he said he enjoyed talking to her.
63. On 23 September, the nurse saw Mr Saliuka and told him that he had been
discharged from the primary care mental health team. Mr Saliuka reiterated that he
did not want this as he had deeper issues to discuss, though he accepted that he
could do this with psychology. The nurse reminded Mr Saliuka about available
support and how he could contact the primary care mental health team again if he
needed to.
64. The same day, the RBG case management assistant and occupational therapist
reviewed Mr Saliuka’s social care needs. Mr Saliuka said that he felt in a state of
“limbo”, as he did not know what was going to happen at his trial in January. He
also said that three talking therapy sessions had helped him and that a move into
an adapted cell with a hospital bed had helped him to sleep properly. They decided
that Mr Saliuka required ongoing support from the care and support orderly.
65. On 4 November, the psychiatrist saw Mr Saliuka for a psychiatry review. At
interview she recalled that Mr Saliuka was upset and agitated and spent a good
deal of time shouting. Mr Saliuka told her that he had a long history of trauma and
was desperate to talk about it, though he did not want to participate in group
sessions. She considered that Mr Saliuka would benefit from some support, so she
referred him to psychology.
66. On 13 November, a trainee counselling psychologist saw Mr Saliuka to assess the
urgency for his psychology appointment. Mr Saliuka described the distressing
events that he had experienced and said that he did not want to discuss these in a
group as he would appear “weak”. Mr Saliuka agreed to wait for a forthcoming
appointment with a specialist psychological therapist.
67. On 21 November, the RBG case management assistant emailed the prison’s Head
of Residence and Safety and told him that RBG had never recommended that Mr
Saliuka needed an adapted cell or said that he could not work (as Mr Saliuka had
said).
68. On 27 November, Mr Saliuka did not see the specialist psychological therapist as
he was on a legal visit.
69. On 3 December, the specialist psychological therapist saw Mr Saliuka for a
psychology assessment. Mr Saliuka said that he suffered with low mood, isolation,
nightmares, anxiety and sudden adrenaline rushes, but had no history of self-harm.
He said that he avoided interacting with other prisoners, because he appeared
weak and vulnerable as a result of his injuries. He also said that he wanted the
therapist to speak to the prison GP so that he could be signed off from working in
the workshop and instead get a wing job as a cleaner.
70. The therapist completed a patient health questionnaire with Mr Saliuka (PHQ-9), a
generalised anxiety disorder questionnaire (GAD7) and a clinical outcomes in
routine evaluation (CORE) questionnaire with Mr Saliuka. These are self-report
questionnaires and Mr Saliuka’s responses suggested that he had severe
depression, severe anxiety disorder and severe psychological distress. However,
the therapist told the investigator that she did not consider opening an ACCT as Mr
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Saliuka answered “not at all” to two questions asking whether he had thoughts of
killing himself. She proposed to see Mr Saliuka for one-to-one cognitive behaviour
therapy (CBT), focusing on ways of managing his anxiety. She said this was due to
start in early January.
71. The same day, the therapist spoke to GP A about Mr Saliuka’s request to work as a
wing cleaner. GP A said that Mr Saliuka had to demonstrate he could work in the
workshop (an entry level job) before he could get a wing job (a highly sought-after
role).
72. On 6 December, an officer saw Mr Saliuka for his first key worker session. Mr
Saliuka told him that he had issues on the houseblock due to the injuries that he
had sustained, and he asked for help with these. On 16 December, the officer saw
Mr Saliuka for another key worker session. Mr Saliuka said that he felt safe and well
in his cell.
73. The key worker told the investigator that he got on well with Mr Saliuka, who he
described as upbeat, confident and very strong-minded. He said that, apart from
speaking about his family, Mr Saliuka only wanted to talk about his injuries, his
dissatisfaction with the way the care and support orderly was cleaning his cell, and
his wish to be allocated a job as a cleaner (which he thought would help his
physical condition and mental state). These were not areas that the officer felt he
could help him with. He was aware that Mr Saliuka’s trial was coming up but said
that he did not seem concerned about it. He said he did not know that Mr Saliuka
had mental health problems and saw no signs that he was using drugs.
74. On 23 December, a custodial manager (CM) emailed the CGL care coordinator and
said that the prison wanted to move Mr Saliuka from the adapted cell but that he
said that the orthopaedic bed had been prescribed to him. The CM asked whether
Mr Saliuka needed an orthopaedic bed and whether he could be moved to a
standard cell. (Belmarsh’s local security strategy states that all standard risk,
Category A prisoners, like Mr Saliuka, must move cells three times in a 12-month
period.)
75. The following day, an RBG team manager emailed the CM and said that RBG’s
social care assessment had not recommended that Mr Saliuka needed a wheelchair
accessible cell or a specialist mattress.
76. The same day, an orthopaedic surgeon examined Mr Saliuka to produce a medical
report for the defence in Mr Saliuka’s forthcoming criminal trial. He noted that Mr
Saliuka limped heavily into the room, using one elbow crutch, and that he cried
when discussing his psychological issues. He concluded that Mr Saliuka’s physical
injuries would satisfy the criteria under the Equality Act 2010 for him to be classed
as permanently disabled.
77. Later that day, GP A saw Mr Saliuka, who said that his chair and mattress provided
by CGL had been briefly taken from his cell. GP A recorded in Mr Saliuka’s
electronic medical record that CGL had provided him with an orthopaedic mattress
and soft chair. On 27 December, a CGL care coordinator emailed the CM, the Head
of Residence and Safety, RBG occupational therapist and CGL project manager
and stressed that CGL had not provided Mr Saliuka with an orthopaedic mattress or
soft chair. (It is unclear who had authorised these items.)
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78. On 27 December, an officer told Mr Saliuka he had to move to another cell (in line
with the regular moves for Category A prisoners) but he refused to do so. The
officer placed him on a disciplinary charge and downgraded him to the basic
regime. Three days later, the Head of Offender Management Services held the
disciplinary hearing. Mr Saliuka did not attend. (Mr Saliuka had been excused from
morning workshop on the basis that it was very difficult for him to get ready in time
due to his stiff joints in the morning. It is not known whether he was given extra time
to attend his disciplinary hearing.) The Head of Offender Management Services
found that the charge was proven as Mr Saliuka went to the gym, so she
considered he was fit to be in any ground floor cell. (There was no
acknowledgement that Mr Saliuka was prescribed remedial gym due to his
disability.) As a punishment, she decided that Mr Saliuka should lose access to
association, the gym, a television and to buy personal items. He was put back on
standard regime.
79. On 30 December, Mr Saliuka’s sister telephoned the prison to raise concerns that
he had not been allowed to make any telephone calls for several days (his last call
had been on 26 December), that he was being bullied by prison staff and that they
were threatening to take his special mattress and chair away. The switchboard
passed Mr Saliuka’s sister to the prison’s safer custody hotline and she left a
message on the answerphone but never received a response.
80. Mr Saliuka called his family late afternoon and said he had been put on basic for
refusing to move cells and this was the first time he had left his cell. He said, “I need
the bed man”, and “I suffered one month without the bed.”
81. On 31 December, staff moved Mr Saliuka from the adapted cell to a standard cell
on Houseblock 4. This meant that he no longer had his special bed and mattress.
Mr Saliuka called his family several times that day. He blamed the doctor for the
move and said that the doctor was telling him one thing and prison staff another. He
said, “Right now my mind’s a mess.”
82. Later that day, GP A saw Mr Saliuka, who was very upset about the change of cells.
GP A noted that Mr Saliuka had been giving different accounts to the different
teams working with him about who had authorised what and he planned to discuss
this with relevant staff, including the CM, the CGL care coordinator and CGL project
manager during a meeting on 6 January 2020 to clarify Mr Saliuka’s medical and
social care needs.
83. On the morning of 1 January, Mr Saliuka telephoned his family and spoke with his
sister. During the call, Mr Saliuka said, “It’s a mess man, my life’s a mess right
now”, though he said nothing else of concern.
84. Later that morning, a CGL healthcare assistant saw Mr Saliuka for a weekly social
care check in. She noted that Mr Saliuka acted aggressively as he was upset about
being moved from the adapted cell. She said that CGL could not resolve this but Mr
Saliuka became angrier so she left.
Events on 2 January 2020
85. At approximately 7.50am on 2 January, Officer A let Mr Saliuka out of his cell so his
care and support orderly could clean it. While the cell was being cleaned, Officer A
spoke with Mr Saliuka, who said he had had enough of Houseblock 4 and wanted to
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move to another houseblock. Officer A spoke with a SO on Houseblock 1, who
refused to accept Mr Saliuka due to his recent negative behaviour.
86. At 10.17am, Mr Saliuka telephoned his family and spoke with his mother and father.
He said nothing of concern.
87. At approximately 10.30am, the care and support orderly finished cleaning Mr
Saliuka’s cell so Officer A asked Mr Saliuka to return to it. Officer A told us that Mr
Saliuka returned to his cell but then became aggressive towards the care and
support orderly and put his foot in the door to stop Officer A from closing it. Officer A
said he managed to shut the door and heard Mr Saliuka say to the orderly, “You
wait until I get out of this cell, I’m gonna fuck you up.”
88. At approximately 11.35am, SO A decided that Mr Saliuka should not be allowed out
of his cell to collect his lunch because of his previous threat to the orderly, so he
took his food to his cell. SO A said he opened Mr Saliuka’s cell and tried to explain
his decision, but he said Mr Saliuka reacted aggressively and forced his way out of
the cell. An officer activated the general alarm and various officers, including SO A
and Officer A, restrained Mr Saliuka. Body-worn camera footage recorded the
restraint and Mr Saliuka is heard saying twice, “You’re fucking with my leg.” The
officers restrained Mr Saliuka for four minutes before returning him to his cell. (The
investigator wrote to the orderly but he declined to be interviewed or provide a
statement.)
89. A nurse responded to the general alarm and examined Mr Saliuka in his cell after
the restraint. Mr Saliuka said that he was in pain but he had no visible injuries. The
nurse took his basic observations, which were normal, and gave him paracetamol
and ibuprofen.
90. Officers started the process for four disciplinary charges but they were not heard
before Mr Saliuka’s death and there was therefore no requirement to move him to
the prison’s segregation unit.
91. There is no record that Mr Saliuka was involved in any other physical or verbal
altercation that day.
92. At 12.21pm, Mr Saliuka pressed his cell bell and Officer B went to Mr Saliuka’s cell
and spoke to him through the observation panel. She said Mr Saliuka told her that
he had “fucked up” but did not know how to fix it and that he knew that he could not
“ride his bang up”. He also spoke about his forthcoming trial (which had been due to
start on 6 January but in December, had been adjourned to start in June) and said
that the Crown Prosecution Service was trying to convict him under joint enterprise,
which he said meant that he could be sentenced to 33 years imprisonment. Officer
B told Mr Saliuka that he would face a disciplinary charge and would probably be
moved to another houseblock. She said he was happy about that and said it would
give him the chance for a fresh start. She said she had no concerns about him
when she spoke to him because he always seemed like a confident person who
had friends on the houseblock.
93. At approximately 2.00pm, a prisoner went to Mr Saliuka’s cell and spoke to him
through the observation panel. He said he asked Mr Saliuka about being restrained
and Mr Saliuka said that his body was hurting. He said Mr Saliuka was angry with
the officers and told him that he had been chatting to officers outside his cell and
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then they had told him to go into his cell and he refused and then they restrained
him for no reason. He said Mr Saliuka felt he had been ‘violated’.
94. In his witness statement, Officer A wrote that, at approximately 5.25pm, SO A
asked officers to begin locking prisoners in their cells. (Mr Saliuka had not been
unlocked because of the earlier incident.) Some minutes later, another officer
realised that Mr Saliuka had not collected his evening meal, so Officer C offered to
deliver it, accompanied by SO A and Officer A. The officers arrived at Mr Saliuka’s
cell but they could not see him, despite switching the cell’s night light on, and he did
not respond to their calls. SO A asked Officer D to get a torch from the prison’s
Orderly Office.
95. Officer D returned with a torch some minutes later. SO A shone the torch through
the observation panel and saw Mr Saliuka kneeling down facing the window, with
his head covered by the curtain. In his witness statement, SO A wrote “this looked
like he was hanging” but that he was worried that it was a trap from Mr Saliuka to
draw staff into the cell, based on his behaviour that day and the fact that he was a
known hostage taker (an intelligence report from 16 July 2017 alleged that Mr
Saliuka had tried to pull an officer into his cell).
96. SO A ran to the wing office and telephoned a CM to tell him about the situation with
Mr Saliuka. The CM told SO A that he needed to go into Mr Saliuka’s cell, for
preservation of life, but that he should be accompanied by three officers in case it
was a trick.
97. SO A, Officer D, Officer E and another officer entered Mr Saliuka’s cell and found
him hanging from a ligature at the back of the cell. At 5.46pm, as noted on the
prison’s Incident Log Sheet, an officer called a code blue emergency (which
indicates that a prisoner is unconscious or having difficulty breathing). SO A cut the
ligature, which was made from a dressing gown cord and had been attached to a
window bar, and they moved Mr Saliuka onto the landing where there was more
room for resuscitation. Two officers started cardiopulmonary resuscitation (CPR).
98. GP A and other healthcare staff quickly responded to the code blue emergency.
They continued CPR, inserted an airway through Mr Saliuka’s nostril, gave him
oxygen and attached a defibrillator, but it did not detect a shockable heart rhythm
and advised to continue CPR.
99. The prison called for an ambulance at 5.46pm. London Ambulance Service sent two
ambulances which reached Mr Saliuka at 6.08pm and 6.10pm respectively, having
each arrived at the prison five minutes earlier. Paramedics took over the
resuscitation attempt, attached a LUCAS chest compression machine and gave Mr
Saliuka adrenaline and sodium chloride, though they were unable to insert an
airway as his jaw was locked. They were unable to resuscitate him and, at 6.32pm,
GP A declared that he had died.
Contact with Mr Saliuka’s family
100. Following Mr Saliuka’s death, the prison appointed a SO as the family liaison officer
(FLO). At 11.35pm, the FLO and an officer visited the home address of Mr Saliuka’s
family and broke the news of his death. They offered their condolences and
support. The family were very shocked and distressed. They were subsequently
contacted by members of the public who told them that Mr Saliuka had been
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restrained shortly before his death and prisoners believed that he had been killed by
staff, possibly accidentally as a result of the restraint and then it had been made to
look like suicide. Mr Saliuka’s family also rejected the prison’s offer of financial
support towards his funeral and repatriation to Kosovo.
101. The FLO spoke to Mr Saliuka’s sister on two further occasions, on 4 and 7 January,
and tried to answer some of the questions that she had. There is no evidence that
there was any further liaison with the family after 8 January.
Events after Mr Saliuka’s death
102. On 3 January, a prisoner told staff that after the restraint he heard Mr Saliuka shout
words to the effect of “I don’t know what to do, I’m broken. I have lost face, what
can I do?” out of his window. (No one else says they heard this.)
103. Also on 3 January, four prisoners went on the netting on Mr Saliuka’s houseblock to
protest about his death. They subsequently wrote individual statements that
referred to them either witnessing or discussing Mr Saliuka being restrained, and
saying that they did not believe he had killed himself. The investigator interviewed
two of these prisoners. (The other two had been released: one did not respond to
our letter to him and the other had died very shortly after his release from prison.)
104. The prisoners both said that Mr Saliuka had been a confident, upbeat person who
got on well with other prisoners, especially with other Albanian and Muslim
prisoners, and seemed positive about being acquitted of the murder charge he was
facing. They said he talked a lot about his injuries and the pain he experienced.
105. One prisoner said that he had witnessed about 30 seconds of the restraint on 2
January from the landing above. He said Mr Saliuka was trying to get up the stairs
and officers were trying to prevent him. He said staff were using a normal amount of
force and he could see Mr Saliuka standing up with his head bent down and an
officer controlling each of his arms. The other prisoner did not witness the restraint
but spoke to Mr Saliuka through his cell door afterwards.
106. Both said they were very surprised when they heard that Mr Saliuka had killed
himself as he did not seem the sort of person who would do so, although one said
there was no way of knowing what other prisoners really thought when they were
alone in their cells. Both also said they were upset that prisoners were not formally
told of Mr Saliuka’s death the next day and that little support was offered.
Support for prisoners and staff
107. After Mr Saliuka’s death, a prison manager spoke to the staff involved in the
emergency response to offer support. The staff care team also offered support.
108. The prison posted notices informing other prisoners of Mr Saliuka’s death, and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Saliuka’s death.
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Post-mortem report
109. The post-mortem examination found that the cause of Mr Saliuka’s death was
partial suspension. The pathologist considered that Mr Saliuka would have rapidly
become unconscious following critical compression of his neck.
110. The pathologist noted that Mr Saliuka had an injury on his chest that appeared to be
a burn caused around the time of his death and was consistent with contact with a
hot radiator. He also noted that Mr Saliuka had other superficial injuries that could
be attributed to the restraint incident but which did not directly cause Mr Saliuka’s
death. He found no serious trauma to Mr Saliuka’s brain or its covering membranes
to indicate that he had been rendered unconscious before he became suspended.
111. Toxicology tests detected a very low level of alcohol in Mr Saliuka’s blood and
urine, which could have been drunk before his death or produced by bacteria
following his death. The tests did not find any other substances (including no trace
of the antidepressant Mr Saliuka was prescribed).
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Findings
112. Mr Saliuka’s family were told by some other prisoners that Mr Saliuka had been
beaten and/or strangled by prison officers who then made his death look like
suicide. We have found no evidence to support this.
113. There is no CCTV or body-worn camera footage to show what happened before
officers restrained Mr Saliuka. However, on the evidence available, we found that
the use of force was justified. Although a prisoner said that Mr Saliuka told him that
officers had restrained him for no reason while he was chatting to them outside his
cell, he also said that Mr Saliuka told him that he had refused to go back into his
cell, and another prisoner said that he saw Mr Saliuka trying to get up the stairs.
This accords with the staff accounts that Mr Saliuka forced his way out of his cell
when officers were trying to close the cell door, pushed past other officers in an
aggressive manner and tried to go up the stairs. We consider that it was reasonable
for staff to feel threatened in these circumstances and to take action to restrain Mr
Saliuka.
114. The investigator watched the body-worn camera footage of the restraint and of Mr
Saliuka being returned to his cell. Although the initial stage as officers struggled to
get control of Mr Saliuka was somewhat chaotic (as is often the case at the
beginning of a restraint), once they had him under control, their behaviour was calm
and controlled, using approved Control and Restraint (C&R) techniques, and they
spoke calmly to Mr Saliuka explaining what they were doing while they took him
back to his cell. Although a prisoner described staff as having Mr Saliuka in a
‘headlock’ (which suggests an arm around the neck or throat) this was not in fact
the case – the body-worn camera footage shows that staff walked Mr Saliuka back
to his cell using the approved C&R method where one officer held his head down
towards his chest with a hand below his chin while other officers controlled each of
his arms.
115. A prisoner spoke to Mr Saliuka after the restraint at about 2.00pm. He said that Mr
Saliuka said that he was in pain after being restrained, but he did not suggest that
staff had beaten him after that. As there is no CCTV on the houseblock, we cannot
say for certain that no one entered Mr Saliuka’s cell between 2.00pm and about
5.25pm when he was found hanged. However, the post-mortem examination found
that Mr Saliuka had suffered only superficial injuries that did not contribute to his
death, and that there was nothing to suggest he had been rendered unconscious
before he became suspended.
Assessment of Mr Saliuka’s risk of suicide and self-harm
116. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), provides a non-exhaustive list of
risk factors and potential triggers that might increase a prisoner’s risk of suicide and
self-harm. It sets out the procedures (known as ACCT) that staff should follow if
they identify a prisoner at risk of suicide or self-harm and highlights the importance
of information sharing.
117. We have considered whether staff at Belmarsh should have recognised that Mr
Saliuka was at risk of suicide and begun ACCT procedures to support him.
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118. Mr Saliuka had some risk factors: he was struggling with his physical and mental
health; he referred to feeling “hopeless” and “low in mood” in discussions with a
mental health nurse; he was assessed as having severe depression, severe anxiety
disorder and severe psychological distress on 3 December; and he was imminently
facing a murder trial, which could have resulted in a lengthy prison sentence. He
had also been restrained on the morning of his death and, even when this is done
entirely legitimately using approved techniques, this can be a painful and
humiliating experience for a prisoner.
119. There is intelligence from October 2016 and March 2017 that Mr Saliuka was
possibly making weapons, and intelligence from December 2011 and January 2016
that Mr Saliuka informed on other prisoners, but there are no intelligence reports of
either behaviour in late 2019 or early 2020. Some staff said that it was alleged that
Mr Saliuka had stolen items from the care and support orderly’s cell (while the
orderly was cleaning his cell) and that this was one reason for their argument on 2
January. However, Mr Saliuka had money in his account when he died, which
suggests he had no reason to steal from other prisoners. We do not, therefore,
consider it likely that these factors played a part in Mr Saliuka’s death.
120. Although Mr Saliuka had a number of risk factors, crucially he had not hurt himself
or tried to take his own life in the past and he had not told anyone, including during
calls to his family, that he had thought about taking his own life. In addition, prison
staff were not aware of Mr Saliuka’s mental health issues and both they and other
prisoners said that he always came across as a confident, upbeat person.
121. As a result, we are satisfied that there was little to suggest to prison staff that Mr
Saliuka was at imminent risk of suicide and self-harm at Belmarsh and we do not
consider that they could have foreseen or prevented his actions.
122. However, we are disappointed that prison staff on Houseblock 4 did not know that
Mr Saliuka’s trial was due to start on 6 January. We are concerned that the lack of
information sharing between prison departments meant that there was limited
opportunity for staff to support or talk to Mr Saliuka about it. Prisoners and staff we
spoke to said that Mr Saliuka was a proud man and was anxious not to appear
vulnerable, and if Mr Saliuka was worried about the outcome of his trial, there is no
guarantee that he would have chosen to open up about it. Nevertheless, we make
the following recommendation:
The Governor should ensure that staff understand the need to record and
share information that may affect a prisoner’s risk.
123. While there was no indication that Mr Saliuka was at imminent risk of suicide, he
had been subject to a series of events that would have had a negative impact on
him and there was little regard to the cumulative effect these actions were likely to
have had. This is discussed more below.
124. We are also concerned that prison staff were not aware that Mr Saliuka had mental
health issues and did not know that the specialist psychological therapist had
assessed that he had severe depression, severe anxiety disorder and severe
psychological distress on 3 December. We discuss this in more detail in the Clinical
Care section below.
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The adapted cell
125. Mr Saliuka was upset and angry at being moved out of the adapted cell and it is
possible that this was playing on his mind on the day of his death.
126. There are two adapted cells on the ground floor of Houseblock 4. They are much
larger than normal cells to allow wheelchair access and have their own shower.
They are primarily designed for prisoners who use a wheelchair. Not every prisoner
with a disability will require a cell with wheelchair access.
127. We have found no evidence that a doctor or anyone else said that Mr Saliuka
required an adapted cell for medical reasons. The most likely explanation for his
temporary occupation of the adapted cell is that it was vacant when he was due to
move cells and that, because of his injuries, prison staff thought it would be an
appropriate location for him. However, Mr Saliuka appears to have believed that he
had been formally allocated an adapted cell for medical reasons and that staff had
therefore behaved inappropriately when they moved him out of a cell which he
believed he was entitled to.
128. As a Category A prisoner, Mr Saliuka was required to move cells every few months
for security reasons. The evidence shows that before Mr Saliuka was moved out of
the cell on 31 December, prison staff checked with all the parties involved – CGL,
RBG and GP A – who all confirmed that he did not require an adapted cell. We are,
therefore, satisfied that there was no reason why staff should not have moved Mr
Saliuka out of the cell, given that he needed to move cells for security reasons. We
note that he was moved to another ground floor cell so he did not have to use the
stairs.
129. It had become unclear who, if anyone, had authorised the adapted cell and Mr
Saliuka’s soft chair and orthopaedic mattress and why, and whether there was a
medical need for them. GP A therefore planned to discuss Mr Saliuka’s needs with
prison, healthcare and social care staff on 6 January to ensure there was clarity
about what his requirements actually were. (If Mr Saliuka required special
equipment, this could have been provided in a standard cell.) We consider that this
was an appropriate way to determine what, if any, special equipment Mr Saliuka
required. Unfortunately, Mr Saliuka died before this meeting took place.
130. While it was a reasonable decision to move Mr Saliuka from the adapted cell, it is
unclear why there was the urgency to move him on 31 December, before the
planned meeting with prison, healthcare and social care staff on 6 January to
discuss his needs. It would have been preferable to await the outcome of that
meeting before moving Mr Saliuka from the adapted cell.
131. We recommend:
The Governor and Head of Healthcare should ensure that where a prisoner
requires special accommodation or equipment for medical or social care
reasons, this is formally authorised and recorded.
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Staff attitudes to Mr Saliuka’s disability and cumulative impact of
actions taken against him
132. Mr Saliuka’s injuries following the car crash in 2018 meant that he met the definition
of disabled under the Equalities Act. Although we found that no one at the prison
had ever recommended an adapted cell for Mr Saliuka, it is likely that he believed
he had been allocated that cell due to his disability. He refused to move, arguably
because he believed he should not be required to move due to his disability, and
that staff had got it wrong.
133. It was clear that some staff did not consider Mr Saliuka as disabled, or at least
considered him less disabled than he actually was, on the basis that he liked to
work out at the gym and had a muscular build. This demonstrated a limited
understanding of disability.
134. Mr Saliuka was placed on a disciplinary charge and downgraded to basic regime for
his refusal to move cells. At the disciplinary hearing, he was found guilty in his
absence with no acknowledgment that he had been prescribed remedial gym due to
his disability and also that he possibly had not been given sufficient time to get to
the hearing. (Though he was put back on standard regime the same day.)
135. It is apparent that these events, which culminated in Mr Saliuka being moved from
the adapted cell to a standard cell, had a very negative impact on Mr Saliuka’s
mental health and, alongside the other issues affecting him, might have resulted in
him taking his life. While the actions taken were not, in isolation, necessarily
unreasonable or discriminatory, we consider that there was a lack of regard of the
potential cumulative impact on Mr Saliuka. It is possible that had there been better
communication with Mr Saliuka about the need for and timing of the move, better
understanding of his perception of staff’s treatment of him and better
acknowledgement of his needs as a disabled man then it would not have had such
a devastating impact on him.
Key worker scheme
136. An HMPPS policy, Manage the Custodial Sentence Policy Framework, requires that
all prisoners should be allocated a prison officer key worker to engage, motivate
and support them throughout their time in custody. Key workers should spend an
average of 45 minutes each week per prisoner on key work duties, including
individual time with each prisoner.
137. Mr Saliuka had been at Belmarsh since 20 July but did not have any key worker
sessions until his first meeting with his key worker on 6 December.
138. After two key worker sessions, Mr Saliuka’s key worker asked to be replaced as he
felt that he could not give Mr Saliuka the help that he needed. However, he
remained Mr Saliuka’s key worker until a replacement could be found. Although he
said he attempted to see Mr Saliuka each week, he told the investigator that he had
to see all his prisoners within a two-week period, not weekly. He said was not able
to see him after 16 December because of Christmas and New Year.
139. We are disappointed that Mr Saliuka was not allocated a key worker for the majority
of his time at Belmarsh. We cannot say that the outcome would have been different
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for Mr Saliuka if he had had the support of a key worker throughout his time at
Belmarsh as he may not have chosen to share his concerns with his key worker,
but it may make a significant difference in other cases. We make the following
recommendation:
The Governor should ensure that prisoners are promptly allocated a key
worker, who is able to see them on a regular basis.
The Safer Custody hotline
140. On 31 December, Mr Saliuka’s sister telephoned Belmarsh’s switchboard and was
put through to the Safer Custody hotline where she left a message on the answer
machine. We do not know precisely what Mr Saliuka’s sister said, though we
understand that she raised the family’s concern that they had not heard from him for
a few days. (We note that Mr Saliuka was still allowed to make telephone calls at
this time but that he had fewer opportunities to do so because he had lost
association as a punishment at his disciplinary hearing.)
141. The Head of Residence and Safety told the investigator that although the hotline’s
answerphone should be checked daily, this message, along with calls about other
prisoners, had been overlooked. He said that, following Mr Saliuka’s death, the
prison has introduced a Care and Keep Safe Log, added an emergency number to
the hotline’s answerphone message and moved control of the hotline to the control
room for any out-of-hours calls. However, we are concerned that answerphone
messages are not checked frequently enough during the day. We make the
following recommendation:
The Governor should ensure that staff regularly check and respond promptly
to messages left on the Safer Custody hotline.
Clinical care
Physical health provision
142. Mr Saliuka suffered several serious injuries in a car accident in 2018. The clinical
reviewer found that healthcare staff considered Mr Saliuka’s physical health in detail
and that they obtained sufficient information from his community GP to provide
effective care. The clinical reviewer considered that Mr Saliuka received a good
standard of care and support from GP A, which was above the level that might be
expected.
143. The clinical reviewer also found that Mr Saliuka received consistent and reliable
support from the social care team, as they saw him on a weekly basis, regularly
reviewed his care and took his concerns seriously.
144. Overall, the clinical reviewer was satisfied that the care that Mr Saliuka received
was equivalent to that which he could have expected to receive in the community.
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Mental health and psychology provision
145. The clinical reviewer said that it was evident that Mr Saliuka was very stressed in
prison, but that there was no real evidence that he had any significant affective
(mood) disorder. However, the clinical reviewer found that the prison GPs’
assessments did not contain enough detail for him to be sure that they had fully
considered a diagnosis of depression.
146. The clinical reviewer noted that a primary care mental health nurse and a forensic
psychiatrist had considered Mr Saliuka’s psychological problems and referred him
for a psychological assessment, to be followed by CBT. The clinical reviewer noted
that the decision to refer Mr Saliuka for a psychological assessment was not
dependent on him seeing a psychiatrist, but that the delay in seeing the psychiatrist
resulted in a further delay to the assessment.
147. Having considered all the information available, the clinical reviewer concluded that
the mental health care Mr Saliuka received was equivalent to that which he could
have expected to receive in the community.
148. While we note the clinical reviewer’s position, we are concerned at the apparent
delays with the psychiatrist’s appointment and the psychological assessment. The
psychiatrist’s appointment had originally been scheduled for 9 September but did
not take place until 4 November, an unexplained delay of nearly two months.
Similarly, a nurse referred Mr Saliuka for a psychological assessment on 30 August,
but the specialist psychological therapist did not attempt to see him until 27
November, another unexplained delay of nearly two months, and arranged to start
therapy sessions with him in early January. We cannot say whether the outcome
might have been different for Mr Saliuka if these assessments had taken place
more promptly. However, we make the following recommendation:
The Head of Healthcare should ensure that psychiatric and psychological
assessments:
• are actioned within a specific timeframe; and
• are not cancelled unless there are justified and documented reasons.
149. We are also concerned that, although the specialist psychological therapist
assessed Mr Saliuka as having severe depression, severe anxiety disorder and
severe psychological distress on 3 December, she did not take any immediate
action and did not plan to see him for one-to-one counselling until early January.
150. The therapist said that she did not consider that Mr Saliuka was at risk because he
denied any thoughts of killing himself. However, as we have said repeatedly over
the years, staff should not assess a prisoner’s risk by focussing exclusively on what
he says about his intentions or how he presents, but should also consider his risk
factors for suicide and self-harm. Given her assessment, we think the therapist
should have considered opening ACCT procedures to provide support for Mr
Saliuka before she was able to start counselling a month later. We consider that
she should also have referred him to a GP or the mental health team to review his
antidepressant medication. As it was, Mr Saliuka was left unsupported for a month
and staff and other prisoners had no idea that he had mental health issues. We
make the following recommendations:
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The Head of Healthcare should ensure that all staff:
• are aware of their responsibility to open an ACCT if they have concerns
that a prisoner may be at risk of suicide or self-harm; and
• understand that they need to consider a prisoner’s risk factors when
assessing his risk of suicide or self-harm, and not focus solely on what
the prisoner says about his intentions or how he presents.
The Head of Healthcare should share this report with the specialist
psychological therapist and discuss the Ombudsman’s findings with her.
Emergency response
Entering the cell
151. On 2 January, Mr Saliuka had threatened another prisoner and been restrained
after he forced his way out of his cell. We are therefore satisfied that it was
reasonable for staff to decide to keep Mr Saliuka locked in his cell and deliver his
evening meal to his cell. We also consider that it was reasonable to obtain a torch
when the officers were unable to see Mr Saliuka using the cell’s night light.
152. However, once the torch arrived, we are concerned about the delay in entering Mr
Saliuka’s cell. In their witness statements SO A and Officer E, respectively, said, “I
knew this looked like he was hanging” and “The only way that he could still be
upright was if something was holding him by his neck,” while Officer D said during
his interview that he could not see Mr Saliuka’s chest rising.
153. During his interview, SO A said that he did not enter Mr Saliuka’s cell with the
officers present because they would not have had the sufficient staff to restrain him
if he had attacked them, that he could have had a weapon and that other prisoners
were still out on the landing. During his interview, Officer A said that he had been
asked to lock prisoners back in their cells before Mr Saliuka was seen hanging.
154. The absence of CCTV cameras on Houseblock 4 means that we have been unable
to determine whether the majority or all prisoners had returned to their cells after
collecting their evening meal and the length of time or urgency shown by staff
between Officer C delivering Mr Saliuka’s meal and the officers entering his cell.
However, what is clear from interviews with prison staff and from reading their
witness statements is that numerous staff, including SO A, Officer A, Officer C,
Officer D and Officer E, were present on Houseblock 4, near to Mr Saliuka’s cell or
in the houseblock’s main office.
155. We understand that SO A would have been cautious given Mr Saliuka’s aggressive
behaviour earlier that day. However, as so many staff were nearby, we do not
consider it was necessary for him to contact the CM for advice when he thought he
could see Mr Saliuka hanging, and that he should have made an immediate
dynamic risk assessment to decide if it was safe for officers to enter Mr Saliuka’s
cell.
156. We are also concerned that SO A did not call an emergency medical code when he
thought he could see Mr Saliuka hanging. This led to a delay before an ambulance
was called. Although this did not affect the outcome in Mr Saliuka’s case (as rigor
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mortis had set in before he was found), it could make a critical difference in other
medical emergencies.
157. We make the following recommendations:
The Governor should ensure that staff call a medical emergency code as
soon as possible if a prisoner appears to be hanging.
The Governor should share a copy of this report with Supervising Officer A
and ensure that a senior manager discusses the Ombudsman’s findings with
him.
158. The lack of operational CCTV cameras on Houseblock 4 means that there are
some gaps in our knowledge of what happened and who did what and when. CCTV
cameras have been installed on Houseblock 4 but the Governor told the
investigator they had not worked for many months and that she had been
unsuccessful in getting money to reactivate them. We are surprised that Belmarsh,
a high security prison, has a houseblock holding Category A prisoners without
CCTV cameras. We note that an officer described Houseblock 4 as having “had the
reputation for some time of being the worst houseblock” and that a prisoner said
“people call it the Gaza”. We also note that Mr Saliuka is the second prisoner to
take his own life on Houseblock 4 in the past year. We make the following
recommendation:
The Governor should ensure that the CCTV cameras on Houseblock 4 are
reactivated or replaced as a matter of urgency.
Resuscitation attempt
159. In March 2016, the National Offender Management Service (now HM Prison and
Probation Service), the Royal College of Nursing and the Royal College of General
Practitioners issued Guidance to support the decision-making process of when not
to perform Cardiopulmonary Resuscitation in prisons and immigration removal
centre (IRC). The guidance, which is based on the European Resuscitation Council
Guidelines for Resuscitation, says, “Resuscitation is inappropriate and should not
be provided when there is clear evidence that it will be futile.” The guidelines say
that resuscitation should not be attempted where rigor mortis (stiffening of the body
that normally starts to appear around two hours after death) is present.
160. During the interview with GP A, he said that Mr Saliuka displayed signs of rigor
mortis when he arrived as his jaw was stiff and his arms were not lying flat by his
side, and that he immediately thought the resuscitation attempt would be futile, but
that he continued it because Mr Saliuka was a young man and he wanted to give
him the best chance of survival. He said that he had not seen the resuscitation
guidance.
161. The clinical reviewer believed that the resuscitation attempt conformed with the
resuscitation guidance but that the possibility of rigor mortis was not considered.
We understand the commendable wish to attempt resuscitation, but staff should
understand that they are not required to carry out CPR in these circumstances.
Trying to resuscitate someone who is clearly dead is distressing for staff and
undignified for the deceased.
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162. We make the following recommendations:
The Governor and Head of Healthcare should ensure that staff are given
guidance about the circumstances in which resuscitation is inappropriate, in
accordance with European Resuscitation Council Guidelines.
The Head of Healthcare should share a copy of this report with GP A and
provide him and the prison’s other GPs with a copy of the resuscitation
guidance.
Family liaison
163. PSI 64/2011 sets out the processes that should be followed when a prisoner dies in
custody. This includes that a family liaison officer must promptly visit the next of kin
to break the news of the death in person whenever possible.
164. Although Mr Saliuka was declared dead at 6.32pm, the FLO did not break the news
of his death to his family until 11.35pm, a delay of five hours. Although it took the
FLO an hour to reach Mr Saliuka’s family’s home address, we consider that the
news should have been broken sooner.
165. We are also concerned that despite repeated requests for an updated Family
Liaison Log, the prison has been unable to provide this. We do not, therefore, know
what family liaison happened after 8 January and what discussions took place with
Mr Saliuka’s family about his repatriation to Kosovo and his funeral. We make the
following recommendations:
The Governor should ensure that a family liaison officer breaks the news of a
death to a next of kin in person as soon as possible, in line with PSI 64/2011.
The Governor should ensure that the Prisons and Probation Ombudsman is
promptly provided with all requested documents following a death in custody,
in line with PSI 58/2010.
Follow up care for prisoners
166. PSI 64/2011 sets out the processes that should be followed in supporting prisoners
following a death in custody. It says that appropriate care and support must be
offered to a cellmate and any other prisoner directly affected by the death, including
all prisoners being monitored under ACCT.
167. Following Mr Saliuka’s death, the prison checked on all prisoners being monitored
under ACCT and made Listeners (prisoners trained by the Samaritans) available on
Houseblock 4.
168. However, on 3 January, four prisoners protested about Mr Saliuka’s death and were
taken to the segregation unit. The investigator interviewed two of these prisoners
who both said that very limited support had been provided by prison staff on
Houseblock 4 and by the Imam during Friday prayers.
169. We make the following recommendation:
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The Governor should ensure that after a prisoner dies, prisoners who were
close to him are informed of the death personally and offered appropriate,
individual support.
Inquest
170. The inquest was held on 24 October 2022 and concluded that Mr Saliuka died by
suicide. The record of inquest said, “Mr Saliuka was found dead on the 2nd of
January 2020 at Belmarsh HMP. Following suicide by partial suspension following
significant and multiple failings. There were repeated failings to consistently
recognise the fact and extent of Mr Saliuka's disability resulting in further failure to
implement reasonable adjustments, specifically relating to the provisions of an
adequate mattress and to conduct an adequate medical assessment, prior to
completing the move from the medical cell. These were significant failures in the co-
ordination of Mr Saliuka’s care, with inadequate record keeping. There were
numerous instances of ill treatment of a discriminatory and dismissive nature, along
with an insufficient willingness to address Mr Saliuka’s concern. We consider the
above to have negatively impacted on Mr Saliuka's mental health and thus
constitute contributing factors to Mr Saliuka's suicide.”
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