Piotr Marszalek

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Piotr Marszalek,
a prisoner at HMP Wandsworth,
on 8 June 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
Our 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 Piotr Marszalek died on 8 June 2021, after being found hanging in his cell at HMP
Wandsworth. He was 34 years old. I offer my condolences to Mr Marszalek’s family and
friends.
Mr Marszalek was awaiting extradition to Poland and had been at Wandsworth since
October 2019. He was an extremely challenging prisoner to manage and was at high risk
of suicide for much of his time at Wandsworth. He was often found under the influence of
illicitly brewed alcohol (‘hooch’) which led to disruptive behaviour. There were reports that
if he was unable to access alcohol, he would get depressed.
He was managed under suicide and self-harm procedures (known as ACCT) eight times,
after several suicide attempts and incidents of self-harm. Staff started the last period of
ACCT monitoring on 29 May 2021. He was being monitored when he died.
I am concerned that staff did not consider managing Mr Marszalek under enhanced ACCT
procedures given his repeated suicide attempts and self-harming behaviour. We found
failings in the ACCT management, including delays, lack of involvement of healthcare staff
and an untrained case manager. On the day he died, Mr Marszalek was not checked every
hour as he should have been.
The investigation found that when Mr Marszalek returned from hospital on 30 May, after a
suicide attempt, he was not seen by healthcare staff and was placed in a cell he had
smashed and flooded the night before. This was unacceptable.
Mr Marszalek was repeatedly disciplined for brewing and using alcohol. He was also
referred to the prison’s drug and alcohol team but refused to engage. The clinical reviewer
considered that more could potentially have been done by the healthcare team to address
Mr Marszalek’s repeated drunkenness.
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 June 2022
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. Mr Piotr Marszalek was recalled to prison in April 2019. In July, after completing his
sentence, he was moved to an immigration removal centre (IRC) pending
deportation to Poland. Two attempts to remove him from the UK failed because he
was disruptive.
2. In October 2019, Mr Marszalek returned to prison custody as the Polish authorities
had issued a warrant for his extradition to Poland to face criminal charges. He was
sent to HMP Wandsworth.
3. Mr Marszalek was often disruptive and was frequently under the influence of illicit
substances, mainly ‘hooch’ (illegally brewed alcohol). Hooch was regularly found in
his cell and as a result he spent time in the segregation unit and on the basic
regime. There were reports that he would get depressed if he was unable to access
alcohol.
4. Mr Marszalek was monitored under suicide and self-harm procedures (known as
ACCT) eight times at Wandsworth. He tried to hang himself several times and also
self-harmed by cutting. Following a fight with his cellmate in August 2020, Mr
Marszalek became increasingly upset about the appearance of his broken nose and
the wait for a hospital appointment to assess and potentially fix it.
5. Staff started the last period of ACCT monitoring on 29 May 2021, after Mr
Marszalek cut his arm. Staff noted that he smelt of alcohol. He subsequently
smashed up his cell causing it to flood. Staff moved him to another cell. In the early
hours of 30 May, staff found Mr Marszalek with a ligature around his neck that was
tied to the cell door handle. He appeared to be under the influence of alcohol and
was unconscious. Staff brough him round and took him to hospital. He returned to
Wandsworth later that morning. Staff took him back to his original cell, which
remained damaged. Staff continued ACCT monitoring and set observations at one
an hour.
6. At 4.25am on 8 June, an operational support grade (OSG), recorded that Mr
Marszalek was watching television and that he spoke to him. At the next check, at
5.40am, the OSG saw Mr Marszalek hanging from a ligature. He radioed for
assistance. When officers arrived, they went into the cell and called a medical
emergency code. They cut Mr Marszalek down and started cardiopulmonary
resuscitation (CPR). Healthcare staff and ambulance paramedics continued
resuscitation attempts but Mr Marszalek was pronounced dead at 6.40am.
Findings
7. Mr Marszalek’s behaviour, his suicide attempts, his self-harming and his issues with
alcohol made him extremely challenging to manage and meant that he was at high
risk of suicide. Despite this, staff did not consider managing Mr Marszalek under
enhanced ACCT procedures.
8. We found deficiencies in the prison’s management of ACCT procedures, including
delays, lack of healthcare input to case reviews and an untrained case manager.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
9. Mr Marszalek should have been checked every hour on the day he died but there
was a gap of 75 minutes between the final two ACCT checks.
10. Mr Marszalek should have been seen by healthcare staff when he returned from
hospital on 30 May. Further, he should not have been placed in a smashed and
flooded cell.
11. The clinical reviewer considered that there could have been a clearer plan on
managing Mr Marszalek’s expectations about his hospital appointment to assess
his broken nose. She also had concerns about delays to his dental treatment.
12. The clinical reviewer noted that Mr Marszalek was referred to Change, Grow, Live
(CGL - the prison’s drug and alcohol team) but he refused to engage. She
considered that more could potentially have been done to try to address his
repeated drunkenness.
Recommendations
• The Governor and Head of Healthcare should ensure that staff manage prisoners at
risk of suicide and self-harm in line with policy, in particular staff should:
• consider using enhanced ACCT case management where there has been a
pattern of serious self-harm;
• have had appropriate ACCT training before taking on the role of ACCT case
manager;
• hold the ACCT assessment interview and first case review within 24 hours of the
ACCT being opened;
• invite healthcare staff to the first case review and hold multidisciplinary case
reviews where possible;
• carry out ACCT checks at the agreed frequency, at unpredictable times; and
• make full, accurate entries in the ongoing record of meaningful interactions
rather than just observations.
• The Governor and Head of Healthcare should ensure that when a prisoner returns
from hospital:
• their healthcare needs are assessed if they are in any of the categories at
paragraph 4 of Annex D of PSI 07/2015; and
• escort staff pass on the hospital discharge form to healthcare staff.
• The Governor should ensure that staff are aware of their responsibilities during
medical emergencies, including that they should call the appropriate medical
emergency code immediately.
• The Governor should ensure that prisoners are not located in cells that are not fit for
occupation.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• The Head of Healthcare should consider, in collaboration with CGL and addictions
services, how to ensure that a full physical and addictions assessment might be
carried out if a prisoner is repeatedly showing signs of drunkenness.
• The Head of Healthcare should ensure that prisoners are kept informed about wait
times for significant outpatient appointments and that the risk of extended wait times
is managed appropriately.
• The Head of Healthcare should:
• examine the waiting time in this case with the dental provider and identify any
specific issues that led to a delay in this case; and
• review the current waiting time list for dental appointments with a view to
ensuring they are in line with contractual expectations.
• The Head of Healthcare, the lead GP and the lead manager of the mental health
service should:
• review the system for the follow up of patients who do not meet the threshold for
input from the mental health team but who continue to be referred; and
• clarify the GP role and the development of shared care plans in such cases.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Wandsworth
informing them of the investigation and asking anyone with relevant information to
contact her. One prisoner responded.
14. The investigator obtained copies of relevant extracts from Mr Marszalek’s prison
and medical records.
15. NHS England commissioned an independent clinical reviewer to review Mr
Marszalek’s clinical care at the prison. The clinical reviewer carried out the clinical
review on their behalf. The investigator interviewed 16 members of staff. Some
interviews were conducted jointly with the clinical reviewer. The interviews were
completed by video and telephone due to the restrictions imposed by the COVID-19
pandemic. The clinical reviewer and a PPO colleague visited Wandsworth to
interview a prisoner.
16. We informed HM Coroner for Inner West London of the investigation, who sent us a
copy of Mr Marszalek’s post-mortem and toxicology reports. We have sent the
coroner a copy of this report.
17. The Ombudsman’s family liaison officer contacted Mr Marszalek’s family to explain
the investigation and ask if they wanted to raise any issues. They asked the
following questions:
• What time did Mr Marszalek die?
• What checks should have been done?
• Were checks done when they should have been?
• Why was Mr Marszalek in a single cell?
We have addressed these questions in this report.
18. We shared our initial report with HM Prison and Probation Service (HMPPS). There
were no factual inaccuracies.
19. We provided Mr Marszalek’s next of kin with a copy of our initial report. They did not
raise any issues or comment on the factual accuracy of the report.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Wandsworth
20. HMP Wandsworth is a local Category B prison in London, with a Category C unit. It
holds up to 1,452 men in eight residential wings. St George’s University Hospital
NHS Foundation Trust provides physical healthcare services at the prison. Mental
health services are provided by South London and Maudsley NHS Foundation
Trust. There is an inpatient unit for up to six prisoners.
HM Inspectorate of Prisons (HMIP)
21. The most recent full inspection of HMP Wandsworth was in March 2018. Inspectors
noted that 38 per cent of prisoners were foreign nationals. They found a third of
prisoners were receiving psychosocial help for substance misuse problems and
prisoners reported that it was easy to obtain illicit drugs. They found that around
450 prisoners were referred to the metal health team each month.
22. HMIP found that Prison Service suicide and self-harm procedures (known as
ACCT) had not improved since the previous inspection and that the management of
safer custody lacked drive and focus. Prisoners who had been subject to ACCT
monitoring told the inspectors that they did not feel supported by staff. The prison
had not implemented the learning from the PPO’s previous fatal incident
investigations.
23. HMIP carried out a Short Scrutiny Visit at Wandsworth in April 2020 to look at how
the prison was responding to the COVID-19 pandemic. While time out of cell had
been necessarily limited, HMIP considered that good attention had been paid to the
provision of in-cell activity, and in-cell telephones were described as a great help for
staff to speak to prisoners and prisoners to their families.
24. HMIP reported that primary mental health applications had increased due to
prisoners’ anxieties about their health and regime restrictions, but these were
managed through in-cell assessment forms, work packs and health information
leaflets. HMIP found that there was a large number of foreign national prisoners,
who were not fluent in English, and not as well informed about pandemic
arrangements.
Independent Monitoring Board
25. 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 31 May 2021, the IMB reported
their concern about the availability of illicit substances which seemed to trigger
aggressive behaviour. The IMB reported that the effects of the COVID-19 pandemic
had impacted on healthcare services delivery.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Previous deaths at HMP Wandsworth
26. Mr Marszalek was the 11th prisoner to die at Wandsworth since June 2019. Of the
previous deaths, three were from natural causes, one was drug-related and six
were self-inflicted. We have previously raised concerns about Wandsworth’s ACCT
management.
27. There were seven self-inflicted deaths at Wandsworth within just over six months
(December 2020 to June 2021). Mr Marszalek’s death was the fifth of these deaths.
One of these deaths (in February 2021) involved another Polish prisoner who, like
Mr Marszalek, was being held on a European Arrest Warrant and awaiting
extradition to Poland.
European Arrest Warrant (EAW)
28. The EAW is a mechanism by which individuals wanted in connection with significant
crimes are extradited between EU member states. (From 1 January 2021, it has
been replaced by the UK-EU Trade and Co-operation Agreement.) When an EAW
is issued, it requires another member state to arrest and transfer a criminal suspect
or sentenced person to the issuing state so that the person can be put on trial or
complete a detention period.
Assessment, Care in Custody and Teamwork (ACCT)
29. 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 supervise the prisoner.
Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011. 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.
30. As part of the process, a caremap (plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison.
31. The PSI says that where a prisoner poses a heightened or exceptional risk of self-
harm, staff should consider managing them under enhanced ACCT procedures. In
such cases, the case review team must be led by a minimum of a Custodial
Manager who will chair the case reviews for as long as the risk dictates that the
prisoner needs to be supported by an enhanced case review.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
32. On 6 November 2018, Mr Piotr Marszalek was remanded to HMP Pentonville for
theft. He was convicted and released later that month but was recalled to prison in
April 2019 as he had not complied with the terms of his licence.
33. On 5 July, after completing his sentence, Mr Marszalek was moved to Heathrow
Immigration Removal Centre (IRC), pending deportation to Poland. There were two
attempts to remove Mr Marszalek to Poland but both failed after he became
disruptive. Mr Marszalek appeared under the influence of illicit substances on
occasions, although he denied any substance misuse.
HMP Wandsworth
2019
34. Mr Marszalek was moved to HMP Wandsworth on 7 October 2019, after the Polish
authorities issued an arrest warrant for charges of actual bodily harm, theft and
driving offences.
35. Between 22 October and 4 November, staff supported Mr Marszalek using suicide
and self-harm prevention procedures (known as ACCT) after he cut his abdomen.
Mr Marszalek said his mental health was “not good” because he had moved around
IRCs and prisons too much. Staff referred him to the mental health team but he
refused to engage.
36. In November and December, Mr Marszalek spent time in the segregation unit
(known as the Care and Separation Unit (CSU)) due to threatening behaviour and
brewing alcohol (hooch).
2020
37. On 21 January 2020, Mr Marszalek was remanded in custody under the Extradition
Act 2003 after Poland issued a warrant for his extradition. (Mr Marszalek applied to
appeal against his extradition but his application was halted temporarily pending the
outcome of a related appeal by another individual. (As far as we know, Mr
Marszalek was still awaiting a decision when he died 16 months later.)
38. On 27 February, while in the CSU, Mr Marszalek tried to hang himself. He was
breathing when found but was taken to hospital as a precautionary measure. Staff
closed the ACCT on 10 March.
39. On 5 May, Mr Marszalek complained of toothache. Only emergency dental
treatment was available at the time due to the COVID-19 pandemic. A clinician saw
him and found no evidence of infection so gave him paracetamol. On 8 May, Mr
Marszalek was taken to the CSU after he had been found intoxicated. He tried to
hang himself later that morning. He was breathing but was taken to hospital. Staff
began ACCT monitoring. Mr Marszalek told staff he was unhappy about being in the
CSU and about not seeing the dentist. On 12 May, a dentist saw Mr Marszalek and
prescribed ibuprofen and an antibiotic. Staff closed the ACCT on 22 May.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
40. On 3 August, Mr Marszalek was involved in a fight with his cellmate. A nurse
attended and noted that Mr Marszalek smelt of alcohol and that his nose was
bleeding. She took his observations and noted that his blood oxygen level was low.
She administered oxygen through a face mask but Mr Marszalek became
aggressive and removed the mask. The nurse took observations later and the blood
oxygen level was satisfactory.
41. The next day, 4 August, Mr Marszalek went to collect his evening meal and
collapsed onto a food trolley. Staff took him to hospital. Hospital staff noticed he
smelt of alcohol and prison staff found a bottle of hooch in his cell. Mr Marszalek
underwent a scan in hospital but no significant injuries were identified. He returned
to prison the same day.
42. On 6 August, Mr Marszalek collapsed in his cell. Staff found more hooch in his cell.
He was taken to hospital where a scan showed he had a broken nose. It was noted
that it could be an old fracture. Mr Marszalek was concerned about the appearance
of his nose and was told that an appointment would be made with the Ear, Nose
and Throat (ENT) department.
43. On 14 August, Mr Marszalek cut his stomach. He told staff he was upset about his
broken nose and that he had not yet returned to hospital to have it treated. Staff
opened an ACCT and requested an urgent mental health assessment. A mental
health nurse assessed Mr Marszalek four days later, on 18 August. Mr Marszalek
said he had no thoughts of suicide or self-harm. The nurse assessed that no follow
up was required.
44. On 19 August, Mr Marszalek tried to hang himself in his cell. He was initially
unresponsive but came round. Staff opened an ACCT. Mr Marszalek said the
trigger for harming himself was his nose injury. Staff added a task to Mr Marszalek’s
electronic medical record (SystmOne) to chase up his hospital appointment (this
was not actioned).
45. On 24 August, Mr Marszalek flooded his cell and staff moved him to the CSU. Mr
Marszalek said he would kill himself and showed staff cuts on his abdomen. Staff
assessed that Mr Marszalek was not suitable to remain in the CSU, so moved him
to a wing where he continued to be monitored under ACCT.
46. On 26 August, staff added another task to SystmOne to chase up Mr Marszalek’s
hospital appointment, which was actioned the same day. Mr Marszalek had a
telephone consultation on 4 September. Hospital staff told him he had been added
to the rhinoplasty clinic, but he might have to wait six months for an appointment.
Staff closed the ACCT the same day.
47. On 1 October, Mr Marszalek was suspected of being under the influence of
psychoactive substances (PS, also known as ‘Spice’). On 12 October, he cut his
stomach with a razor blade. Staff from Change, Grow, Live (CGL, the prison’s drug
and alcohol team) met Mr Marszalek the next day for the first time. They saw him a
further five times and gave him a hooch in-cell information pack. Mr Marszalek
initially refused to engage, but eventually agreed to be referred to the Hooch
Support Group. There is no evidence that he attended this (possibly because the
prison was still subject to a restricted regime due to COVID-19).
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
48. On 31 December, Mr Marszalek cut his chest. The nurse who saw him thought he
was intoxicated with alcohol. Staff moved him to the CSU for observation, as no
constant observation cells were available. During an ACCT review, Mr Marszalek
said he had harmed himself because it was the anniversary of his grandfather’s
death. He was offered but declined talking therapy. He requested medication to
help him sleep, but the doctor refused to prescribe anything as Mr Marszalek was
under the influence of an illicit substance.
2021
49. Mr Marszalek returned to A Wing on 1 January 2021. On 4 January, he tried to
hang himself. A nurse noted that officers had told her that Mr Marszalek drank
alcohol and that when he could not get hold of any, he got depressed.
50. The same day, a dentist saw Mr Marszalek. The dentist provided some immediate
treatment and a plan for fillings and root canal treatment when the situation allowed
(treatment was still restricted due to COVID-19).
51. On 11 January, a psychiatrist saw Mr Marszalek. Mr Marszalek said he self-
harmed, particularly by cutting, when he felt frustrated. The psychiatrist noted Mr
Marszalek had borderline personality disorder (a condition characterised by
emotional instability, distorted patterns of thinking and impulsive behaviour) and
was at high risk of suicide, due to his impulsiveness. Mr Marszalek said he did not
want to engage with any talking therapy or any form of mental health treatment.
52. The psychiatrist asked the prison to consider moving Mr Marszalek from a single
cell, so he had a cellmate. A member of the mental health team emailed safer
custody to ask for this to be considered. The safer custody team reviewed Mr
Marszalek’s Cell Sharing Risk Assessment (CSRA) but they assessed that he was
still too high risk to share a cell because of his disruptive behaviour and previous
fights.
53. On 21 January, prison staff asked a nurse to assess Mr Marszalek, who seemed
under the influence of an illicit substance, but he refused to engage. The next day,
22 January, staff found Mr Marszalek unresponsive on his cell floor. He gradually
regained consciousness and staff suspected he was under the influence of alcohol.
He was seen again an hour later, when he seemed much more alert, but still
smelled of alcohol. Later that night, Mr Marszalek smashed a chair in his cell and
burst a pipe, flooding his cell. He also made superficial cuts to his chest. He still
smelt of alcohol and was moved to the CSU. Staff found 35 litres of hooch in his
cell. He returned to a wing the next day and remained on an ACCT.
54. During an ACCT review, Mr Marszalek told staff his main reason for harming
himself was the issue with his nose. Healthcare chased his hospital appointment
again and were advised to check again in four weeks.
55. On 7 and 11 March, staff suspected Mr Marszalek had drunk alcohol. They
searched his cell and found a bottle of hooch.
56. Mr Marszalek was again monitored under ACCT between 5 and 16 April after he cut
his chest. At an ACCT review he mentioned the issue with his nose again.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
57. Healthcare staff noted Mr Marszalek had a hospital appointment for 23 July. They
told Mr Marszalek a hospital appointment had been arranged but could not give him
the exact date for security reasons.
29 May - 7 June 2021
58. On the evening of 29 May, Mr Marszalek cut his arm. Staff opened an ACCT and
took him to the treatment room where healthcare staff treated his wounds. Staff
noted he smelt of alcohol and searched his cell, where they found hooch. Mr
Marszalek told them he had self-harmed because of his nose and was crying about
his appearance. Soon afterwards, Mr Marszalek said he wanted to sleep and asked
to go back to his cell. Staff checked again for alcohol, and then Mr Marszalek
returned. Shortly afterwards, he smashed and flooded the cell, and seemed even
more intoxicated.
59. A prison manager decided to move Mr Marszalek to the CSU, but when they arrived
there, they found there were no free cells. While waiting in a holding cell, Mr
Marszalek banged his head on the wall. The prison manager decided to move Mr
Marszalek to a cell on D Wing, usually used as a constant observation cell. While
they were getting the cell ready, Mr Marszalek again banged his head on a wall.
The prison manager instructed two officers to sit with him and they all chatted. An
officer noted in the ACCT ongoing record that Mr Marszalek seemed much calmer
at 2.30am, and at 3.00am his belongings from his cell on A Wing were brought to
him. Mr Marszalek remained upset about the injury to his nose. At 3.37am, Mr
Marszalek started to fall asleep. The prison manager withdrew the staff from the cell
and asked them to check Mr Marszalek every 30 minutes.
60. At 4.03am, a member of staff on duty on D Wing checked Mr Marszalek and saw he
had tied a ligature around his neck to the cell door handle. Mr Marszalek gained
consciousness quickly and did not need any medical intervention, but when the
paramedics arrived it was decided that Mr Marszalek should go to hospital. They
were concerned that he seemed under the influence of alcohol and had lost
consciousness briefly.
61. Mr Marszalek returned to Wandsworth at 10.15am that morning. He remained on
two ACCT checks an hour. Staff took him back to his cell on A Wing, which he had
smashed and flooded the night before. The escorting staff did not tell healthcare
staff Mr Marszalek had returned and did not pass the hospital discharge note to
them. They remained unaware he had returned from hospital until night duty staff
(who had been on the wing the night before) returned to work.
62. A nurse tried to assess Mr Marszalek’s cut arm later that night, but he would not let
her. He seemed in a low mood, and the nurse noted she would refer him to the
mental health team and ask about Mr Marszalek having a cellmate.
63. The duty governor checked Mr Marszalek’s ACCT document on the afternoon of 30
May. He noted, “The document in poor order…no assessment (still in time) and no
first review. The entrys [sic] in the past 24 hours appear to be observations only and
there is no evidence of quality engagement.” (The ACCT assessment and first case
review should be held within 24 hours of the ACCT being opened.)
64. Shortly after 9.00am on 30 May, an officer carried out the ACCT assessment
interview with Mr Marszalek. A Supervising Officer (SO) held the first case review
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
straight afterwards, with an officer. Mr Marszalek continued to be concerned about
his nose and when he would have a hospital appointment. The SO told him that an
appointment had been arranged. The SO reduced observations to hourly.
65. On 1 June, a mental health nurse assessed Mr Marszalek in his cell. Mr Marszalek
said he did not want her to see his face because it was “messed up” and hid under
a blanket. The mental health nurse continued with the assessment. She tried to
discuss Mr Marszalek’s drinking, but he refused to engage with her apart from
saying he had no mental health problems. She completed a risk assessment for Mr
Marszalek. She noted his impulsivity and anger and that he had refused any further
engagement with CGL. She assessed that no further input from the mental health
team was required, as Mr Marszalek did not seem to have a serious mental health
condition.
66. The healthcare team received a letter on 3 June, which said that Mr Marszalek’s
hospital appointment had been rescheduled from 23 July to 24 September. Mr
Marszalek refused to allow healthcare staff to assess the wounds on his arm or
have his dressing changed.
67. On 4 June, a SO arranged an ACCT case review for Mr Marszalek, with a manager
and a nurse. However, Mr Marszalek appeared under the influence of an illicit
substance and could not attend, so it was rearranged for the next day (although for
operational reasons, the ACCT review could not be held on 5 June).
68. The SO and a nurse carried out Mr Marszalek’s next ACCT review on 6 June. He
appeared tired and withdrawn and said he was not in a good place and had not had
a drink for two days. Again, he spoke about his nose and that he had not been
given a hospital appointment. He was also worried about some missing property
from when he moved from his smashed cell, and the SO agreed to check this for
him. The nurse told Mr Marszalek that drinking increased his risk of suicide and
self-harm. Staff agreed to refer Mr Marszalek to the mental health team and CGL,
although he was not keen to engage with them. They kept observations at hourly.
69. On 7 June, a nurse attempted to remove Mr Marszalek’s stitches, but he seemed
drowsy and unsteady on his feet. She decided to see him later that day. He
appeared more alert later but refused to have the stitches removed or his dirty
dressing changed. The nurse told wing staff she suspected Mr Marszalek may have
taken PS, and they should search his cell. There is no record of this being done.
She noted on SystmOne that healthcare staff should try to remove Mr Marszalek’s
stitches again the next day.
8 June 2021
70. At 4.25am on 8 June, an operational support grade (OSG) carried out Mr
Marszalek’s hourly ACCT check. He recorded that Mr Marszalek was awake and
watching television and that they spoke to each other.
71. At 5.40am, the OSG carried out another ACCT check. He looked through the
observation panel and saw Mr Marszalek was suspended from a ligature made from
a bed sheet and attached to the ceiling. He radioed for staff assistance.
72. Two officers responded. They went straight into Mr Marszalek’s cell and cut the
ligature. One of the officers called a code blue and the control room called an
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
ambulance at 5.43am. They checked for a pulse, but found none, so an officer
began chest compressions. He noticed Mr Marszalek looked very pale, and his lips
appeared purple. The other officer radioed for healthcare assistance.
73. Two minutes later, at 5.42am, a nurse arrived at the cell. She radioed a message to
two other nurses to collect their emergency bags and come to Mr Marszalek’s cell.
They had heard over the radio that a prisoner had ligatured. The nurses assessed
Mr Marszalek. They were unable to find a pulse, noted he was not breathing and he
felt cold. An officer continued with chest compressions. A nurse applied a
defibrillator (a device to shock a heart into a normal rhythm) but the machine
advised no shock. Staff gave Mr Marszalek oxygen and rescue breaths as well as
continuing chest compressions. Mr Marszalek remained unresponsive throughout.
74. Paramedics arrived at Mr Marszalek’s cell at 6.02am. The ambulance was delayed
entering the prison due to a faulty gate, but paramedics left the ambulance and
went to the wing on foot. They took over the resuscitation attempt, but pronounced
Mr Marszalek’s death at 6.40am.
Contact with Mr Marszalek’ s family
75. An officer was appointed as the prison’s family liaison officer (FLO). He and a
member of safer custody staff visited Mr Marszalek’ s family at approximately
10.30am on 8 June to tell them he had died.
76. The prison contributed to the cost of Mr Marszalek’s funeral, in line with national
guidelines.
Support for prisoners and staff
77. After Mr Marszalek’s death, a 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.
78. The prison posted notices informing other prisoners of Mr Marszalek’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 Marszalek’s death.
Post-mortem report
79. The post-mortem report concluded Mr Marszalek died from ligature compression.
No drugs were detected.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of Mr Marszalek’s risk of suicide and self-harm
80. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures (known
as ACCT) that staff should follow when they assess that a prisoner is at risk of
suicide and self-harm.
81. Mr Marszalek’s behaviour, his suicide attempts, self-harm and drinking meant that
he was extremely challenging to manage. During his 19 months at Wandsworth, Mr
Marszalek tried to hang himself several times and also self-harmed by cutting. He
was managed under ACCT eight times. Given the severity and frequency of Mr
Marszalek’s self-harm, we consider that staff should have considered using
enhanced ACCT case management (which uses a more senior case review team).
82. We also found that ACCT procedures were not always managed correctly.
83. PSI 64/2011 says that the ACCT assessment interview and first case review should
take place within 24 hours of the ACCT being opened. Mr Marszalek’s last ACCT
was opened on 29 May but the ACCT assessment interview and first case review
were not held until 31 May. We note that Mr Marszalek spent time at hospital on the
morning of 30 May, but he was back at the prison by 10.15am, so we do not
understand why the ACCT assessment and first case review were not held later
that day. We are also concerned that a SO, who chaired the case review, had not
received ACCT case manager training.
84. We are concerned that Mr Marszalek’s ACCT observations were reduced from
twice an hour to once an hour at this case review, even though he had cut himself
and attempted to hang himself in the previous two days and it is not obvious that
anything had changed. We consider this was premature given Mr Marszalek’s
recent history. He remained on hourly observations until he died.
85. PSI 64/2011 says that healthcare staff should always be invited to the first case
review and that case reviews should be multidisciplinary where possible. There was
no healthcare input to the first case review on 31 May and a number of other case
reviews had no healthcare staff in attendance. Given Mr Marszalek’s concerns
about his nose injury and staff concerns about his substance misuse and the
possibility that he was suffering from depression, we would have expected
healthcare involvement in every ACCT review.
86. Mr Marszalek should have been checked every hour on 8 June. The OSG checked
Mr Marszalek at 4.25am and saw him watching television. He next checked him at
5.40am, 75 minutes later, so well outside the hour.
87. PSI 64/2011 says that ACCT observations should be at unpredictable times. There
were occasions when Mr Marszalek’s checks were carried out at regular, and
therefore predictable, times.
88. We note that when the duty governor carried out a quality assurance check on the
ACCT document on 30 May, he found that the entries in the ongoing record were
observations only and there was no evidence of quality engagement. It was good
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
practice to carry out a quality assurance check, but unfortunately there is no
evidence that anything changed as a result.
89. We recommend:
The Governor and Head of Healthcare should ensure that staff manage
prisoners at risk of suicide and self-harm in line with policy, in particular
staff should:
• consider using enhanced ACCT case management where there has been a
pattern of serious self-harm;
• have had appropriate ACCT training before taking on the role of ACCT
case manager;
• hold the ACCT assessment interview and first case review within 24 hours
of the ACCT being opened;
• invite healthcare staff to the first case review and hold multidisciplinary
case reviews where possible;
• carry out ACCT checks at the agreed frequency at unpredictable times;
and
• make full, accurate entries in the ongoing record of meaningful
interactions rather than just observations.
Mr Marszalek’s return to prison on 30 May
90. Mr Marszalek was not seen by healthcare staff when he returned to Wandsworth
from hospital on 30 May. PSI 07/2015, Early days in custody, says that prisoners
returning after a temporary absence need only be medically assessed if they are in
a category that puts them at enhanced risk of suicide and self-harm (as listed at
paragraph 4 of Annex D). Given that Mr Marszalek was returning from hospital after
a suicide attempt, we consider that he should have been seen by healthcare staff.
In addition, the escorting staff did not pass the hospital discharge sheet to a
member of healthcare staff. We recommend:
The Governor and Head of Healthcare should ensure that when a prisoner
returns from hospital:
• their healthcare needs are assessed if they are in any of the categories at
paragraph 4 of Annex D of PSI 07/2015; and
• escort staff pass on the hospital discharge form to healthcare staff.
91. Mr Marszalek was returned to the cell he had smashed and flooded before being
taken to hospital. This was unacceptable. We recommend:
The Governor should ensure that prisoners are not located in cells that are
not fit for occupation.
92. The psychiatrist and a nurse thought that Mr Marszalek might self-harm less if he
had a cellmate. The prison did consider this, most recently on 19 March 2021, but
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Mr Marszalek’s behaviour meant his risk to other prisoners was too high to allocate
him a shared cell.
Substance misuse
93. Wandsworth recognised that PS and alcohol use was a concern at the prison and
issued a PS and alcohol strategy in 2020. The strategy covers educating prisoners
about the risk, reducing access, holding those involved to account and offering
support.
94. Mr Marszalek was frequently under the influence of illicit substances, mainly hooch.
He was managed in line with the local strategy, including being given education on
the risks of hooch, being subject to cell searches, being dealt with through the
disciplinary process, and being placed on the basic regime. Attempts were also
made to get him to engage with the substance misuse service, CGL, but he was
unwilling to accept their help.
95. None of the action taken made any difference: Mr Marszalek continued to use
hooch throughout his time at Wandsworth. The clinical reviewer noted that Mr
Marszalek’s drinking was primarily considered as a disciplinary issue. She said that
there is no evidence of a clinically focussed discussion with Mr Marszalek about the
risks his drinking posed, even though there is evidence that it was affecting his
mental health and a nurse told him it increased his risk of self-harm.
96. The clinical reviewer also said that there is no evidence that either CGL or
healthcare staff considered asking the local addictions team or a dual diagnosis
specialist to see Mr Marszalek. (Dual diagnosis is where there is substance misuse
alongside mental health issues.) Mr Marszalek might have refused to engage, but,
given the extreme nature of his drinking and the problems it was causing, we agree
with the clinical reviewer that this approach should have been considered.
97. We recommend:
The Head of Healthcare should consider, in collaboration with CGL and
addictions services, how to ensure that a full physical and addictions
assessment might be carried out if a prisoner is repeatedly showing signs of
drunkenness.
Mr Marszalek’s extradition
98. Impending removal from the UK can be a trigger for self-harm and suicide for
foreign national prisoners. PSI 2011/52, Immigration, Repatriation and Removal
Services, says:
“Foreign national prisoners can often experience isolation in prison due to
language and cultural difficulties and lack of family visits and support. Prison
staff should be aware of the heightened risk of self-harm in these cases and
particular care should be taken when serving documentation relating to
deportation which could cause distress.”
99. Extradition under a European Arrest Warrant is a criminal justice matter, rather than
an immigration matter. This was not one of the cases we sometimes see where
immigration officials at the Home Office are responsible for keeping foreign
Prisons and Probation Ombudsman 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
nationals informed about their possible deportation. In this case it was for the court
and Mr Marszalek’s own lawyers to keep him updated about his appeal against
extradition. However, the effect on Mr Marszalek was likely to be very similar: he
apparently did not want to be extradited to Poland and he had spent 19 months
waiting to hear whether this was going to happen or not.
100. We are concerned that there is no evidence that anyone at Wandsworth considered
whether this might be having an effect on his mental wellbeing, or took any steps to
try to obtain an update on when a decision might be made.
Emergency response
101. When the OSG saw Mr Marszalek hanging, he radioed for staff assistance. It was
not until two officers arrived that they called an emergency code blue. This resulted
in a short delay in healthcare staff attending and in an ambulance being called. We
consider that the OSG should have called the code blue as soon as he saw Mr
Marszalek hanging. We recommend:
The Governor should ensure that staff are aware of their responsibilities
during medical emergencies, including that they should call the appropriate
medical emergency code immediately.
Clinical issues
Physical health
102. Mr Marszalek was upset about the appearance of his broken nose and was
frustrated about the wait for a hospital appointment. The clinical reviewer noted that
there was little evidence that his nose damage was causing Mr Marszalek
significant breathing difficulties and therefore he would not have been a priority
case for surgery. In addition, the COVID-19 pandemic had led to longer waits for
outpatient appointments and non-emergency surgery. There were also delays in Mr
Marszalek receiving dental treatment.
103. The clinical reviewer noted that while Mr Marszalek was seen and reviewed many
times by healthcare staff, there was no clearly formulated management plan across
health and custodial care to manage his expectations and needs. Mr Marszalek
may not have responded to such a plan, especially as he become more erratic and
drank more heavily, but in terms of trying to coordinate his care and empower staff
to manage challenging and distressing behaviour, a clear and shared approach
would have been supportive. We recommend:
The Head of Healthcare should ensure that prisoners are kept informed about
wait times for significant outpatient appointments and that the risk of
extended wait times is managed appropriately.
16 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Head of Healthcare should:
• examine the waiting time in this case with the dental provider and identify
any specific issues that led to a delay in this case; and
• review the current waiting time list for dental appointments with a view to
ensuring they are in line with contractual expectations.
Mental health
104. Mr Marszalek was seen many times by the mental health team and was most
recently assessed on 1 June 2021. Staff never identified any evidence of serious
mental illness so he was never added to the mental health team’s caseload. A
psychiatrist assessed that Mr Marszalek may have a personality disorder,
characterised by impulsiveness, that put him at increased risk of suicide. However,
Mr Marszalek refused to engage with any psychological therapy which may have
enabled him to challenge his thinking and reduce his self-harming behaviour.
105. Although Mr Marszalek refused referral to psychology, he did agree to a referral for
bereavement counselling in May 2020. However, there is no record that this was
taken forward.
106. The clinical reviewer noted that Mr Marszalek reported symptoms and behaviour
suggestive of depression and said that he had been given a diagnosis of
depression and medication many years earlier. There are also references to Mr
Marszalek ‘self-medicating’ with alcohol. However, there is no evidence of any
clinically focussed discussion with a GP to consider the possible introduction of
antidepressant medication. The clinical reviewer considered that such a discussion
was indicated, even though Mr Marszalek may have refused medication.
107. The clinical reviewer noted that there was no evidence that Mr Marszalek lacked the
mental capacity to make the decisions he did.
108. We recommend:
The Head of Healthcare, the lead GP and the lead manager of the mental
health service should:
• review the system for the follow up of patients who do not meet the
threshold for input from the mental health team but who continue to be
referred; and
• clarify the GP role and the development of shared care plans in such
cases.
Prisons and Probation Ombudsman 17
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Inquest
109. The inquest was held from 15 to 26 July 2024. The jury concluded that Mr
Marszalek died by suicide and found that:
“A probable cause was his mental health exacerbated by:
1. His injury to his nose and the uncertainty regarding his hospital appointment
date possibly heightened by his extradition to Poland.
2. Possibly due to the amount of time spent in a single cell during COVID and
lockdown within HMP Wandsworth.
3. Possibly due to frustration caused by loss of property.
A second probable cause being the observations of his cell on 7 and 8 June 2021
establishing a predictable pattern with poor quality engagement. Some observations
exceeded the required hourly intervals.
A possible cause was the inadequate communication between prison service and
health service.
Another possible cause was the failure to capture accurate and complete
information from ACCT review on health care system.
A third probable cause was the inadequate management of risk by not recognising
Mr Marszalek’s change of behaviour on 6 June 2021 ACCT review.”
18 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE