Marek Witulski

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Independent investigation into
the death of Mr Marek Witulski,
a prisoner at HMP Peterborough,
on 9 July 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.
This 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 Marek Witulski died in hospital on 9 July 2020, after being found hanging in his cell at
HMP Peterborough three days earlier. He was 50 years old. I offer my condolences to Mr
Witulski’s family and friends.
This is a disturbing case. Mr Witulski was a Polish national and was due to be deported to
Poland at the beginning of April 2020. However, due to the COVID-19 pandemic, the
Home Office was unable to book flights until June, and then the flights were repeatedly
cancelled. As a result, Mr Witulski remained in prison.
The reasons for Mr Witulski’s continued detention were outside the prison’s control.
However, we are very concerned that staff did not do more to keep him informed of the
situation and to check on his welfare, especially as he spent long periods locked in his cell
for long periods because of the COVID-19 restrictions. When Mr Witulski’s family raised
concerns in May about the effect Mr Witulski’s continued detention was having on his
mental health, staff failed to check on his welfare or make a referral to the mental health
team.
We are also concerned that although Mr Witulski spoke very little English, staff rarely used
interpretation services to communicate with him, and that some interactions with him were
not documented in his prison record.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Elizabeth Moody
Deputy Prisons and Probation Ombudsman March 2021
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 23 January 2020, Mr Marek Witulski, a Polish national, was sentenced to eight
months in prison for causing death by careless driving. He was sent to HMP
Peterborough.
2. On 2 April, the Home Office served Mr Witulski with a deportation order. Mr
Witulski waived his right of appeal and agreed to return to Poland. However, due to
the COVID-19 pandemic, the Home Office was unable to arrange flights to Poland.
Mr Witulski was due to be released from prison on 23 May (halfway through his
sentence) but instead he continued to be detained at Peterborough under
immigration powers pending his deportation to Poland.
3. On 22 May, Mr Witulski’s son and the Polish Embassy contacted the prison with
concerns about Mr Witulski’s continued detention and the effect on his mental
health. A safer custody manager told the Polish Embassy that prison staff would
refer Mr Witulski to the mental health team. This did not happen.
4. Attempts were made to deport Mr Witulski to Poland on 1, 16, 20 and 25 June, but
the flights were cancelled due to the COVID-19 pandemic. A further flight was
booked for 5 July and Mr Witulski’s family were expecting him to return home, but
this flight was also cancelled.
5. At around 3.25pm on 6 July, Mr Witulski’s cellmate returned from the exercise yard
to find Mr Witulski unconscious in the cell. Mr Witulski had used a belt to strangle
himself. Staff immediately called a medical emergency code and started
cardiopulmonary resuscitation (CPR). Healthcare staff arrived shortly afterwards
and took over resuscitation attempts until paramedics arrived at around 3.30pm.
Paramedics took Mr Witulski to hospital, but he never regained consciousness and
died on 9 July.
Findings
6. Mr Witulski was detained for around three months after he expected to be deported
to Poland. During this time, he spent most of the day in his cell because of the
COVID-19 restrictions, and his interactions with staff and other prisoners were
further restricted because of his very poor English.
7. While we accept that the reasons for Mr Witulski’s continued detention were outside
the prison’s control, we are very concerned that staff did not do more to
communicate the reasons to him, to check on his welfare and to assess his risk to
himself.
8. Staff failed to refer Mr Witulski for an assessment with the mental health team or to
check on his welfare after his family and the Polish Embassy raised concerns about
his wellbeing on 22 May.
9. There is no evidence that staff had any meaningful interaction with Mr Witulski after
3 March. Although we were told that the prison’s foreign national co-ordinator
spoke to him after his flight to Poland was cancelled on 20 June, there is no record
of this in Mr Witulski’s prison record (NOMIS).
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10. We found that the prison’s local operating procedure (LOP) on the use of translation
services was unclear and there were times when prison and healthcare staff did not
use appropriate methods to communicate with Mr Witulski. We consider that the
LOP requires clarification.
Recommendations
• The Director should ensure that, where a prisoner’s family expresses concerns
about a prisoner’s wellbeing, staff should take immediate action to:
• assess the prisoners needs and make appropriate referrals, as necessary;
and
• clearly document the concerns and the agreed actions in the prisoner’s
NOMIS record.
• The Director should ensure that staff:
• promptly inform foreign national prisoners of any delay to their expected
release/deportation date;
• carry out a face-to-face welfare check, using the services of an interpreter if
necessary, to assess the prisoner’s risk in the event of any delay to their
expected release/deportation date; and
• clearly document the discussion, risk assessment, and actions taken in the
prisoner’s NOMIS record.
• The Director should ensure that all relevant interactions with prisoners, including
those with the foreign national coordinator, are accurately recorded in the prisoner’s
NOMIS record.
• The Director and Head of Healthcare should ensure that staff use approved
interpretation services to communicate with non-English speaking prisoners when
discussing confidential or complex matters.
• The Director should ensure that the prison’s local operating procedure on
translation services is revised to make it clear when approved interpretation
services must be used and when it is appropriate to use staff or prisoners as
unofficial interpreters.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Peterborough
informing them of the investigation and asking anyone with relevant information to
contact her.
12. The investigator obtained copies of relevant extracts from Mr Witulski’s prison and
medical records.
13. NHS England commissioned an independent clinical reviewer to review Mr
Witulski’s clinical care at the prison. The investigator interviewed six members of
staff in November 2020. Due to coronavirus restrictions, the interviews were
conducted by telephone.
14. We informed HM Coroner for Cambridgeshire and Peterborough of the
investigation. The Coroner gave us the results of the post-mortem examination.
We have sent the Coroner a copy of this report.
15. One of the Ombudsman’s family liaison officers contacted Mr Witulski’s family (in
Polish) to explain the investigation and to ask if they had any matters they wanted
the investigation to consider. They raised no issues.
16. We shared our initial report with HM Prison and Probation Service (HMPPS). They
pointed out some factual inaccuracies which have been amended in this report.
17. We sent a copy of our initial report (in Polish) to Mr Witulski’s family. They did not
identify any factual inaccuracies. They raised some queries which we responded to
in separate correspondence.
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Background Information
HMP/YOI Peterborough
18. HMP/YOI Peterborough is operated by Sodexo Justice Services. It holds men and
women in separate sides of the prison. There is 24-hour healthcare provision. All
healthcare is provided by Sodexo under the provisions of their contract with the
Ministry of Justice.
HM Inspectorate of Prisons
19. The most recent inspection of HMP/YOI Peterborough men’s prison was in July
2018. Inspectors reported that levels of self-harm were slightly higher than
comparator prisons. They noted that risks were identified well during the reception
interview and that staff managed suicide and self-harm procedures appropriately.
However, many prisoners felt unsafe and unsupported. Inspectors noted that
records of conversations with prisoners did not always evidence meaningful
engagement by staff.
20. At the time of the inspection, 101 foreign national prisoners were held. Inspectors
noted these prisoners received a reasonable level of support compared to other
diverse groups. However, inspectors noted that professional telephone interpreting
services were not used consistently across the prison and, in particular, these
services were lacking during the reception and induction process.
Independent Monitoring Board
21. 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 March 2019, the IMB reported
that the prison had put considerable effort into training staff and managing suicide
and self-harm. They noted many examples where staff had successfully engaged
with troubled residents, but they felt some documentation was lacking in detail. The
Board noted that the foreign national team offered support to overseas prisoners
within three days of arrival.
Previous deaths at HMP/YOI Peterborough
22. Mr Witulski was the fifth prisoner to die at Peterborough since July 2018. Of the
previous deaths, one was self-inflicted and three were from natural causes. There
are no similarities between our findings in the investigation into Mr Witulski’s death
and our investigation findings for the previous deaths.
Early Removal Scheme
23. The Criminal Justice Act 2003 introduced the Early Removal Scheme (ERS) for
foreign national prisoners. The mandatory scheme allows fixed-term foreign
national prisoners, who are confirmed by the Home Office to be liable to removal
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from the UK, to be removed from prison and the UK up to a maximum of 270 days
before the halfway point of their sentence.
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Key Events
24. On 23 January 2020, Mr Marek Witulski, a Polish national, was sentenced to eight
months in prison for causing death by careless driving. He was sent to HMP
Peterborough. It was his first time in prison.
25. The Person Escort Record (PER - a document that accompanies prisoners between
police custody, courts and prisons, which sets out the risks they pose) noted that Mr
Witulski had a previous history of self-harm ‘over a year ago’. It also said that Mr
Witulski spoke very little English. When Mr Witulski arrived at Peterborough, the
reception officer noted that there were no current concerns about suicide or self-
harm.
26. The reception nurse used a telephone interpretation service during the reception
screening. She noted that Mr Witulski had type 2 diabetes and high blood pressure
and he had brought in his own medication. She noted that he had no current
mental health concerns. The next day, a GP prescribed medication for diabetes
and high blood pressure.
27. On 30 January, Mr Witulski had an unallocated key worker session (meaning that a
permanent key worker had not yet been allocated to him). There is no record that
an interpreter was used. The key worker noted that Mr Witulski said he would
probably be released after two months and just wanted to do his time peacefully.
28. On 11 February, Mr Witulski had a healthcare screening. Staff asked another
prisoner to act as interpreter.
29. On 18 February, Mr Witulski met with his allocated key worker. The key worker
noted that he was unable to hold a full discussion as Mr Witulski could not speak
English. He said that next time he would bring along someone who could speak
Polish.
30. On 20 February, the Home Office served Mr Witulski with a notice of intention to
deport him from the UK to Poland. Mr Witulski signed a disclaimer stating he did
not wish to make any representations against his proposed deportation.
31. Mr Witulski’s key worker met with Mr Witulski again on 23 February and 3 March.
The key worker told the investigator that he used a Polish-speaking prisoner as an
interpreter on both occasions. However, the notes of the key worker sessions
indicate that the key worker had difficulties communicating with Mr Witulski and
there is no mention of a Polish-speaking prisoner being present.
32. Mr Witulski’s key worker recorded on 23 February that Mr Witulski expressed
concern that no one had checked his blood sugar for his diabetes for “a long time”,
and on 3 March that he said his diabetes was getting bad as he was running out of
medication. The key worker recorded that he took Mr Witulski to speak to the
nurses and have his medication re-ordered, but there is no record of this in Mr
Witulski’s medical records.
33. Mr Witulski’s key worker told the investigator that Mr Witulski was focused on
returning to Poland and he did not want to engage with any work or activity in
prison. He said he had no concerns about Mr Witulski. There were no key worker
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sessions after 3 March. The key worker told the investigator that he was off work
so was unable to hold further key worker sessions.
34. Mr Witulski was eligible for the Early Removal Scheme (ERS), meaning that he
could be deported to Poland after serving only one quarter of his prison sentence.
The prison’s foreign national co-ordinator told the investigator that Mr Witulski was
therefore eligible for deportation around the end of March. On 31 March, the Home
Office issued a deportation order to be served on Mr Witulski.
35. On 2 April, the foreign national co-ordinator met with Mr Witulski and served the
deportation order. He did not use an interpreter for the meeting, but he told the
investigator he thought that Mr Witulski understood him. Mr Witulski waived his
right of appeal and signed the paperwork to say he agreed to return to Poland.
36. However, due to the COVID-19 pandemic resulting in a national lockdown and
border closures in several countries, Home Office staff were unable to arrange a
flight to Poland for Mr Witulski. Records show significant communication between
the foreign national co-ordinator and the Home Office attempting to arrange a flight
for Mr Witulski. However, there is no record that prison staff told Mr Witulski about
these difficulties.
37. On 22 May, Mr Witulski’s son wrote to the prison asking why his father continued to
be detained and expressing concerns about his mental health, saying Mr Witulski
could “no longer withstand mentally”. He said that Mr Witulski had expected to be
released after eight weeks yet had remained in prison for more than four months.
On the same day, the Polish Embassy sent an email to the safer custody team at
the prison expressing similar concerns about Mr Witulski’s mental health on behalf
of his family.
38. On 26 May, a safer custody manager replied to the Polish Embassy by email. He
wrote that wing staff said that Mr Witulski had no issues and that he had been
expecting to be released on 22 May but was told he would be remaining in prison
under immigration detention. He also wrote, “I have asked staff to raise a referral
for Mr Witulski to see our mental health team”.
39. The safer custody manager told the investigator that he had contacted wing staff to
ask them to carry out a welfare check on Mr Witulski and, if necessary, to make a
referral to the mental health team. We found no record of this. He said he believed
it was the responsibility of the wing staff to carry out the welfare check and any
follow up action. He could not say why the mental health referral was not made or
why the information was not documented in Mr Witulski’s prison record (NOMIS).
40. A Senior Prison Custody Officer (SPCO) said that he became aware some time
after 26 May that the safer custody team had contacted the wing about Mr Witulski.
He told the investigator that he was not directly involved in following up any action
about Mr Witulski’s welfare, but he thought other members of staff on the wing
might have been. He said he did not know which members of staff were involved or
what action had been taken. He said that he thought any follow up action should
have been the responsibility of the safer custody team. There is nothing in Mr
Witulski’s prison record to show that any member of the wing staff had checked on
his welfare.
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41. Records show that attempts were made by the Home Office to fly Mr Witulski back
to Poland on 1, 16, 20 and 25 June, but the flights were cancelled by the airline.
The foreign national co-ordinator told the investigator that he went to speak to Mr
Witulski after the flight was cancelled on 20 June. He said he was accompanied by
a Polish-speaking member of staff as he wanted to explain to Mr Witulski why he
had not yet returned to Poland. He said he thought that Mr Witulski understood the
problem with the flights. He said that Mr Witulski took the news well and he had no
concerns about him after they spoke. He did not make a note of this conversation
in Mr Witulski’s prison record.
42. Around 30 June, a Polish-speaking English tutor spoke to Mr Witulski while she was
delivering work to other prisoners on the wing. She told the investigator that Mr
Witulski said he was annoyed that his flights had been cancelled. She told him that
it was probably due to the pandemic. She said Mr Witulski was angry and
frustrated but that she had no concerns about him.
43. Records show that on 3 July (incorrectly dated 3 June), the foreign national co-
ordinator replied to an email apparently received from Mr Witulski’s son on 17 June.
He apologised for the uncertainty and confusion. He said that Mr Witulski remained
detained as the airline had cancelled a number of flights. He said that that flights
had now resumed, and Mr Witulski was booked on a flight to Poland on 5 July,
arriving in Warsaw at 9.45pm. Mr Witulski’s family were therefore expecting him
home. However, the flight was again cancelled by the airline, but we found no
evidence that this message was communicated to Mr Witulski or his family. The
foreign national co-ordinator told the investigator that he did not speak to Mr
Witulski after 20 June.
44. At around 3.25pm on 6 July, Mr Witulski’s cellmate returned from the exercise yard
to find him unconscious in the cell. Mr Witulski had placed an upturned chair on the
top bunk bed and attached a belt to the chair. He then placed the belt around his
neck and knelt down, resulting in self-strangulation. Staff immediately removed the
ligature from his neck and radioed a code blue (an emergency code which tells the
control room that a prisoner is unresponsive or not breathing and that an
ambulance needs to be called immediately). Healthcare staff arrived shortly
afterwards and took over resuscitation attempts until paramedics arrived at around
3.30pm. Paramedics took Mr Witulski to hospital, but he did not regain
consciousness and died there on 9 July.
Contact with Mr Witulski’s family
45. At 5.50pm on 6 July, the prison appointed a family liaison officer. She contacted Mr
Witulski’s wife by phone to tell her that her husband had been taken to the hospital.
A Polish-speaking prison officer was also present to act as an interpreter. Mr
Witulski’s family were with him at the hospital when he died on 9 July.
46. The Prison Service arranged the repatriation of Mr Witulski’s body to Poland and
contributed towards the cost of his funeral in line with national policy.
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Support for prisoners and staff
47. After Mr Witulski’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
48. The prison posted notices informing other prisoners of Mr Witulski’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 Witulski’s death.
Post-mortem report
49. The post-mortem report concluded that the cause of death was asphyxia due to
hanging. The toxicology report showed no presence of illicit drugs or alcohol in Mr
Witulski’s body.
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Findings
Assessment of Mr Witulski’s risk of suicide and self-harm
50. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), gives guidance to staff on how to
identify, manage and support prisoners who are at risk of harm to themselves or
others. It sets out the procedures (known as ACCT) that must be followed
whenever staff assess that a prisoner is at risk of suicide or self-harm.
51. At the time of sentencing, Mr Witulski expected that he would be deported to Poland
within two months under the Early Removal Scheme. He told staff this when he
arrived at Peterborough and said he just wanted to do his time peacefully. Despite
signing the necessary deportation paperwork at the end of March, he continued to
be detained under immigration powers beyond his conditional release date of 23
May.
52. We have seen evidence that the Home Office repeatedly tried to book Mr Witulski
on a flight to Poland and that their failure to do so was due to restrictions caused by
the COVID-19 pandemic. We also accept that this was outside the prison’s control.
53. However, we consider that Mr Witulski’s continued detention is likely to have been a
source of distress and frustration for him. Although the foreign national co-ordinator
said Mr Witulski was always polite and appeared accepting of the situation, the
English tutor (who spoke Polish) said he was angry and frustrated, and his son said
the situation was affecting his mental wellbeing.
54. We are, therefore, very concerned that there is no evidence that anyone explained
the reasons for the delay to Mr Witulski or considered what effect the situation might
be having on his mental health. Indeed, there is no record that any member of staff
had any meaningful interactions with Mr Witulski at all in the four months after his
last key worker session on 3 March. Given Mr Witulski’s circumstances – detained
well beyond the date on which he expected to be released, locked up for in his cell
for most of the day because of the COVID-19 restrictions, and isolated by his
inability to speak English – we consider this was unacceptable.
55. We are particularly concerned that there is no record that anyone checked on Mr
Witulski’s wellbeing even after his family and the Polish Embassy contacted the
prison directly in May to express concern. Although a safer custody manager told
the Polish Embassy that Mr Witulski would be referred to the mental health team,
this did not happen. Neither the safer custody team nor wing staff took responsibility
for this failure. The safer custody manager said he expected the wing staff to take
responsibility, and the SPCO said he saw this as the responsibility of the safer
custody team. Neither recorded this at the time nor took any steps to ensure that
someone was taking action. Mr Witulski appears to have fallen through the cracks
as a result.
56. The foreign national co-ordinator told us that that he spoke to Mr Witulski about the
delays on 20 June, but he made no record of this. We are very concerned that no
one checked on Mr Witulski after his flight was cancelled on 5 July, despite knowing
that his family were expecting him home.
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57. We recommend:
The Director should ensure that staff:
• promptly inform foreign national prisoners of any delay to their
expected release/deportation date;
• carry out a face-to-face welfare check, using the services of an
interpreter if necessary, to assess the prisoner’s risk in the event of
any delay to their expected release/deportation date; and
• document the discussion, risk assessment, and actions taken in the
prisoner’s NOMIS record.
The Director should ensure that, where a prisoner’s family express concerns
about a prisoner’s wellbeing, staff should take immediate action to:
• assess the prisoners needs and make appropriate referrals, as
necessary; and
• document the concerns and the agreed actions in the prisoner’s NOMIS
record.
Record keeping
58. We found that some interactions staff said they had with Mr Witulski were not
recorded in his prison record. In addition, those entries that were made did not
always accurately reflect the interactions. For example, Mr Witulski’s key worker
said that he had two key worker sessions with Mr Witulski with a Polish-speaking
prisoner as an interpreter, but he did not record this at the time (and instead
recorded that it was difficult to have a discussion with Mr Witulski because of his
poor English).
59. None of the interactions between Mr Witulski and the foreign national co-ordinator,
or any other staff from the foreign national team, were recorded in his prison record.
We recommend:
The Director should ensure that all relevant interactions with prisoners,
including those with the foreign national coordinator, are accurately recorded
in the prisoner’s NOMIS record.
Interpretation services
60. The prison’s local operating procedure (LOP) on translation services says that staff
should use an approved telephone interpretation service to communicate effectively
with non-English speaking prisoners. The LOP goes on to say, “Where possible we
will use both staff and other residents who have language skills to help us
communicate with residents who do not speak English.”
61. However, the LOP makes it clear that for reasons of privacy and accuracy staff and
other prisoners should not be used as interpreters for ACCT reviews, medical
interviews or adjudications. An operational manager at the prison told the
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investigator that staff are expected to use the interpretation service for key worker
sessions, but this is not entirely clear from the LOP.
62. We found that healthcare staff used the approved interpretation service to complete
Mr Witulski’s healthcare reception screening. Otherwise, we found that a
combination of staff and prisoners were used to translate conversations between Mr
Witulski and members of staff, including for key worker sessions. This is
unacceptable and we were particularly concerned to find that a healthcare
assessment on 11 February was carried out with a Polish-speaking prisoner as an
interpreter.
63. While we understand that there may be occasions when it might be appropriate to
use staff or prisoners to interpret, we consider that guidance on the use of the
official interpretation service requires clarity. We make the following
recommendations:
The Director and Head of Healthcare should ensure that staff use approved
interpretation services to communicate with non-English speaking prisoners
when discussing confidential or complex matters.
The Director should review the prison’s local operating procedure to ensure
that staff are clear when approved interpretation services must be used and
when it is appropriate to use staff or prisoners as unofficial interpreters.
Inquest
64. At the inquest, held from 29 September to 10 October 2025, the jury concluded that
Mr Witulski died by suicide by hanging due to the failure of the combined
authorities.
65. They found that, “Due to lack of communication between the Home Office and
prison, and incorrect risk assessments, he was not offered the correct support.
There was also insufficient relevant information given to the custody officers….After
the COVID lockdown started and his official release date passed, neither he nor his
family were informed of the possibility of applying for immigration bail by either the
Home Office or prison….If all the information had been acted on, such as an ACCT
being opened, a mental health referral being made and Mr Witulski and his family
being kept adequately informed, the probability is he would have been released on
bail and would not have self-harmed.”
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