Piotr Zmijewski

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Independent investigation into
the death of Mr Piotr Zmijewski,
a prisoner at HMP Maidstone,
on 9 September 2023
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.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Piotr Zmijewski died after being found in his cell at HMP Maidstone on 9 September
2023 with a ligature tied around his neck. He was 49 years old. I offer my condolences to
Mr Zmijewski’s family and friends.
I have concluded that Mr Zmijewski gave no obvious indication to staff that he was at risk
of suicide. However, in the weeks leading up to his death, Mr Zmijewski chose to self-
isolate, meaning he spent periods of the day confined to his cell. I found no evidence that
staff attempted to engage in meaningful conversation with him during these periods and,
as a result, opportunities to properly assess the risk he posed to himself were missed.
Maidstone has a robust self-isolation policy with clear guidelines on how staff should
support a prisoner during periods of self-isolation. However, staff failed to properly
implement this policy: they did not review Mr Zmijewski’s self-isolation plan regularly or
seek input from other professionals who may have been able to provide additional support.
However, I also recognise that Mr Zmijewski’s self-isolation was inconsistent, and it was
difficult for staff to assess the level of threat he genuinely felt.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman March 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. In January 2019, Mr Piotr Zmijewski was charged with violent offences and
remanded to custody. In October, he was sentenced to 14 years imprisonment.
Prison records note that over the next four years, he appeared settled and gave no
indication that he was a risk of suicide or self-harm. Having spent time in a number
of prisons, on 13 June 2023, Mr Zmijewski transferred to HMP Maidstone.
2. On 27 June, Mr Zmijewski referred himself to the mental health team because he
said he was having trouble sleeping, was depressed and was not coping on his
wing. Staff booked him an appointment to see a GP on 4 July. He did not attend this
appointment. Staff rebooked the appointment but again, he did not attend. Staff did
not record the reasons why or offer him a further appointment.
3. On 22 August, Mr Zmijewski was discussed at the weekly SIM (Safety Intervention
Meeting), after he reported to wing staff that he felt in danger from other prisoners
on the wing. The next day, a member of the chaplaincy team visited him in his cell
to discuss his concerns. Mr Zmijewski said he was going to keep himself safe by
self-isolating. Staff opened a self-isolation log so they could monitor and support
him.
4. Over the next few days, the self-isolation log remained open, however staff also
recorded that Mr Zmijewski left his cell at least once a day, unescorted, to access
parts of the regime.
5. On 28 August, a supervising officer completed Mr Zmijewski’s weekly self-isolation
review. This contained limited information but noted that Mr Zmijewski was leaving
his cell to access parts of the regime on a regular basis. Despite this, the self-
isolation log remained open.
6. On 30 August, an officer took Mr Zmijewski’s dinner to him in his cell, as per the
self-isolating procedures. Mr Zmijewski asked for his cell to be left unlocked and
spent the next hour associating with peers on his wing.
7. On 9 September at approximately 1.19pm, an officer went to check on Mr Zmijewski
in his cell. He opened the observation panel and saw Mr Zmijewski sitting on the
floor with a ligature tied around his neck. The officer immediately entered the cell,
pressed the alarm on his radio, and cut through the ligature.
8. Approximately one minute later, additional officers responded to the alarm, entered
Mr Zmijewski’s cell, and radioed a code blue (a medical emergency code used
when a prisoner is unconscious or having breathing difficulties). Staff started
cardiopulmonary resuscitation (CPR). Two minutes later, healthcare staff arrived
and took over Mr Zmijewski’s care.
9. At approximately 1.30pm, paramedics arrived and took over resuscitation attempts.
At 2.01pm, the paramedics pronounced that Mr Zmijewski had died.
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Findings
10. We found that when Mr Zmijewski began self-isolating, staff correctly opened a self-
isolation log and spoke with him to understand his motivation for doing so. Mr
Zmijewski said that he felt unsafe, but staff had very limited evidence to suggest
that there was an actual threat to his safety at Maidstone. We found no further
evidence during the course of our investigation. We consider that from this point
onwards, the management of his self-isolation was poor, and not taken seriously by
staff. There was little evidence of robust case management of his self-isolation log,
daily updates and weekly reviews did not take place as they should have done,
there was no multidisciplinary input from partner agencies and there was limited
information about identified risks and agreed actions to reduce or end isolation.
Healthcare staff did not check on him as they should have done.
11. We found that, in the weeks prior to his death, Mr Zmijewski gave no indication to
staff that he was at risk of suicide and that they could not have foreseen his actions.
However, we consider that staff interactions with Mr Zmijewski during this period
were minimal and as a result, opportunities to properly assess the risk he posed to
himself were missed.
Recommendations
The Governor and Head of Healthcare should ensure that:
• plans for isolating prisoners contain detailed information about identified
risks and agreed actions to reduce or end isolation,
• prison staff regularly review plans and ensure that any changes are
recorded and actioned; and
• healthcare staff review and document the mental state of a self-isolating
prisoner at least once a week.
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The Investigation Process
12. The PPO was notified of Mr Piotr Zmijewski’s death on 11 September 2023. The
investigator issued notices to staff and prisoners at HMP Maidstone informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
13. The investigator obtained copies of relevant extracts from Mr Zmijewski’s prison
and medical records.
14. NHS England commissioned a clinical reviewer to review Mr Zmijewski’s clinical
care at the prison. The investigator and clinical reviewer conducted joint interviews
with eleven members of staff. In April 2024, the investigation was reallocated to
another investigator.
15. We informed HM Senior Coroner for Mid Kent & Medway of our investigation. She
gave us the results of the post-mortem examination. We have sent her a copy of
this report.
16. The Ombudsman’s family liaison officer contacted Mr Zmijewski’s daughters to
explain the investigation and to ask if they had any matters they wanted us to
consider. Mr Zmijewski’s daughters wanted to know all the circumstances that led to
his death. They said that Mr Zmijewski had told them that he did not feel safe in
prison and had been threatened. They said that they had reported this to the prison.
17. Mr Zmijewski’s daughters received a copy of the draft report. The solicitor
representing them wrote to us pointing out some factual inaccuracies. The report
has been amended accordingly. They also raised a number of questions that do not
impact on the factual accuracy of this report. We have provided clarification by way
of separate correspondence to the solicitor.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Maidstone
19. HMP Maidstone is a training prison that holds foreign national prisoners. Almost all
the population is of interest to Home Office Immigration Enforcement (HOIE) which
has a team, called the In Prison Team (IPT) on site in the prison.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Maidstone was in October 2022. Inspectors
reported prisoners’ anxiety had increased due to Home Office delays in processing
their immigration cases. Self-harm rates were low, although they observed
widespread anxiety and distress. Some staff were alert to this, while others were
less forthcoming in offering informal support. Records of interactions with prisoners
were often missing, and supervisors did not always complete their daily checks.
More prisoners than at the previous inspection said they felt unsafe, attributing this
to their uncertain immigration status, but others raised concerns about debt and
antisocial behaviour.
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 2022 to 2023, the IMB reported
that mental health issues were made worse because of the additional complications
of being a foreign national in a British prison and the stress caused by the way
immigration issues were handled. The IMB noted that prison and healthcare staff
worked hard to alleviate mental health issues and were noticeably compassionate
in the support they provided.
Previous deaths at HMP Maidstone
22. Mr Zmijewski was the fourth prisoner to die at Maidstone since 9 September 2020.
One of the previous deaths was self-inflicted, one from natural causes and the other
was a homicide. There were no similarities between our findings in these deaths
and Mr Zmijewski’s death. Up until the end of August 2024, there had been one
further death at Maidstone due to natural causes since that of Mr Zmijewski.
Key worker scheme
23. The key worker scheme was introduced in the men’s prison estate in 2018. It
provides prisoners with an allocated officer that they can meet regularly to discuss
how they are and any day-to-day issues they would like to address. Improving
safety is a key aim of the scheme. All adult male prisoners should have around 45
minutes of key work each week, including a meaningful conversation with their
allocated officer.
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24. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
Self-isolation
25. Self-isolation is when a prisoner chooses to isolate themselves from the prison’s
regime and remain locked in their cell for an extended period. Reasons why a
prisoner chooses to isolate vary, and staff should discuss the motivation for self-
isolation with the prisoner so they can take appropriate action to mitigate any
threats and encourage the prisoner to re-engage with the regime.
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Key Events
Background
26. On 25 January 2019, Mr Piotr Zmijewski was charged with violent offences and
remanded to HMP High Down. Mr Zmijewski was a Polish national, and it was his
first time in prison in the UK.
27. On his arrival at High Down, Mr Zmijewski said he had no thoughts of suicide or
self-harm. Reception staff noted that he had no history of suicide attempts, self-
harm or mental ill-health.
28. On 24 October, Mr Zmijewski was sentenced to 14 years imprisonment. Over the
next four years, he was transferred to several prisons including HMP Woodhill,
HMP The Mount, HMP Hewell and HMP Wandsworth. Throughout this time, Mr
Zmijewski engaged in the prison regime, attended work and gained some basic
literacy and numeracy qualifications. His ability to speak English improved and in
some instances he became able to communicate with staff without an interpreter.
Prison records show that he appeared settled and gave no indication that he was at
risk of self-harm or suicide.
HMP Maidstone
29. On 13 June 2023, Mr Zmijewski transferred to HMP Maidstone. Both first and
second reception screenings were unremarkable and consistent with those from
other prisons. There was no known or disclosed drug, alcohol or mental health
history. Mr Zmijewski was of interest to Home Office Immigration Enforcement
officials.
30. On 27 June, Mr Zmijewski referred himself to the mental health team, saying that he
was having trouble sleeping, was depressed, and was not coping on the wing. Staff
triaged the referral and made Mr Zmijewski a GP appointment for 4 July. Mr
Zmijewski was sent a slip notifying him of this appointment.
31. On 4 July, Mr Zmijewski did not attend his GP appointment. Staff rescheduled the
appointment for 7 July, and again sent him a slip to notify him. Mr Zmijewski did not
attend this appointment either. The appointment was not rebooked, and staff did not
record why he had not attended.
32. On 22 August, staff discussed Mr Zmijewski at the weekly SIM (Safety Intervention
Meeting), after he reported to wing staff that he felt in danger from other prisoners
on the wing. The next day, a member of the chaplaincy team visited him in his cell
to discuss his concerns. Mr Zmijewski said that a prisoner had been to his cell door
and told him that he was “dead”. He said that he believed this was due to previous
issues he had with prisoners while at The Mount, and that prisoners thought he was
an informer (a prisoner who covertly gives security information to staff). Maidstone
checked Mr Zmijewski’s prison records before speaking to staff at The Mount who
said he had not been an informer there. Mr Zmijewski said he was going to keep
himself safe by self-isolating in his cell.
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33. Later that day, staff opened a prisoner self-isolation log and spoke to Mr Zmijewski
about why he was self-isolating. Mr Zmijewski said that he had been threatened by
another prisoner but could not name them and said he would not feel safe in any
other wings at Maidstone. Mr Zmijewski said that he would like to be transferred to
another foreign national prison.
34. A few hours later, Mr Zmijewski’s daughter rang the prison to tell them he had been
threatened and that she was worried for his safety. An officer from the safer custody
team assured her that they were aware of the situation and that they were looking
at ways to support him.
35. On 24 August, Mr Zmijewski attended a routine appointment in healthcare. Despite
self-isolating, he told an officer he did not need escorting to his appointment.
36. Over the next few days, Mr Zmijewski’s self-isolation log remained open. However,
staff recorded that Mr Zmijewski left his cell at least once a day, unescorted, to
access parts of the regime. This included attending the chapel and collecting his
meals. An entry in the self-isolation log stated that Mr Zmijewski may have been
self-isolating in an attempt to obtain a transfer to another prison, closer to his family.
There is, however, no record of this being discussed with him.
37. On 28 August, a Supervising Officer (SO) completed Mr Zmijewski’s weekly self-
isolation review. The review contained little information and it is not clear if Mr
Zmijewski was present. The SO recorded that Mr Zmijewski was leaving his cell to
access parts of the regime on a regular basis. Despite this, the self-isolation log
remained open.
38. On 30 August, an officer took Mr Zmijewski’s dinner to him in his cell, as per the
self-isolating procedures. Mr Zmijewski asked for his cell to be left unlocked and
spent the next hour associating with peers on his wing. He remained unlocked until
the evening routine check, two hours later. There are no further entries in the self-
isolation log from this date, nor are there any recorded entries on Mr Zmijewski’s
prison or healthcare records until the day of his death.
39. Mr Zmijewski made daily calls to his daughters from his prison phone. The last call
he made was on 6 September (he had sufficient funds to make calls after this date).
The investigator received translations of these calls and there was nothing that
indicated Mr Zmijewski was a risk to himself. Mr Zmijewski also received regular
visits from his family. The last visit he received was on 3 September, and he had a
visit scheduled with his daughter for the day after his death.
Events of Saturday 9 September
40. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to prison radio communications from 9 September. She also obtained
information from the Southeast Coast Ambulance Service. The following account
has been taken from all sources.
41. At approximately 11.45am, an officer went to Mr Zmijewski’s cell to give him his
lunch. At interview, he told us that he unlocked the door, gave Mr Zmijewski his
lunch, and asked him if he was okay. Mr Zmijewski said “I’m okay” before taking his
lunch and being locked back into his cell. He described Mr Zmijewski as looking
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“worried” but said that this was not different to how he usually looked, and he was
not concerned.
42. At approximately 1.15pm, an officer began unlocking the cells for afternoon
activities. He did not unlock Mr Zmijewski’s cell as he believed he was still self-
isolating. At 1.19pm, he went to check on Mr Zmijewski in his cell. He opened the
observation panel and saw Mr Zmijewski sitting on the floor with a ligature tied
around his neck and secured to his cabinet. He immediately opened the cell door,
pressed the alarm button on his radio, and asked a prisoner who was standing
nearby to press the general alarm. Upon entering the cell, he cut through the
ligature and the prisoner helped him put Mr Zmijewski into the recovery position.
43. Approximately one minute later, two officers and a SO responded to the alarm and
entered Mr Zmijewski’s cell. At 1.21pm, an officer radioed a code blue (a medical
emergency code used when a prisoner is unconscious or having breathing
difficulties). Control room staff requested an ambulance immediately.
44. At 1.22pm, the SO checked Mr Zmijewski to see if he had a pulse before moving
him onto his back and starting cardiopulmonary resuscitation (CPR). Over the next
few minutes, the officers took turns doing CPR and another SO arrived with a
defibrillator (a device that gives shocks to the heart to restore a normal heartbeat).
45. At 1.24pm, a nurse and a healthcare assistant arrived and staff moved Mr
Zmijewski to the corridor where there was more room. Healthcare staff applied the
defibrillator and continued resuscitation attempts.
46. At approximately 1.30pm, paramedics arrived and took over resuscitation attempts.
At 2.01pm, the paramedics pronounced that Mr Zmijewski had died.
Contact with Mr Zmijewski’s family
47. At 2.45pm, the prison appointed two family liaison officers. At 3.40pm, they left the
prison and travelled to Mr Zmijewski’s daughter’s home address. At 5.45pm, they
arrived at the address but found that Mr Zmijewski’s daughter no longer lived there.
As a result, they agreed to visit the home address of Mr Zmijewski’s second
daughter. Upon arrival, they found both of Mr Zmijewski’s daughters were there and
so, at 6.15pm, one FLO informed them of the death of their father and offered his
condolences.
48. Maidstone contributed to Mr Zmijewski’s funeral costs in line with national guidance.
Support for prisoners and staff
49. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners to identify prisoners most affected by
the death.
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50. The prison posted notices informing other prisoners of Mr Zmijewski’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 his death. Staff checked on
the welfare of the prisoner involved in the emergency response and told him about
support services available to him at Maidstone, should he need them.
51. After Mr Zmijewski’s death, the staff involved in the incident were given the
opportunity to discuss any issues arising. They were also offered support by the
staff care team and signposted to support services available to them. Arrangements
were made for the staff who were directly involved in the incident to be taken home
and the Governor contacted them the following day to check on their welfare and
offer additional support.
Post-mortem report
52. The post-mortem report recorded Mr Zmijewski’s cause of death as hanging.
53. At the inquest held on 3 February 2025, the coroner concluded that Mr Zmijewski
died by suicide.
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Findings
Assessment of risk
54. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of suicide or self-harm posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under ACCT procedures. PSI 64/2011
also states that any information that becomes available which may affect a
prisoner’s risk of harm to self must be recorded and shared, to inform proper
decision making. Mr Zmijewski had several risk factors including that it was his first
time in prison, he was facing extradition proceedings, he felt at risk of harm from
other prisoners, he was self-isolating, and he missed his family. However, he had
no recorded history of suicidal thoughts or attempts, or self-harm.
55. We found that, in the weeks prior to his death, Mr Zmijewski gave no indication to
staff that he was at increased risk of suicide and that they could not have foreseen
his actions. However, staff interactions with Mr Zmijewski during this period were
minimal and as a result, opportunities to properly assess the risk he posed to
himself were missed. These opportunities included self-isolation procedures, key
working and mental health support and are discussed further below.
Self-isolation
56. It is essential for staff to recognise the heightened risks associated with specific
situations and groups of prisoners, including isolating prisoners. Governors must
have a system in place to identify and accurately record details of all isolating
individuals within the establishment. Records must include the reasons given for
isolating, support offered, and the details of regime being offered and taken. This
information must be made available in local SIMs to inform decisions about any
subsequent supportive actions or interventions to mitigate the risk of continued
isolation.
57. Maidstone’s self-isolation policy states that a collaborative approach between prison
staff and partner agencies should provide regular and consistent intervention to
support prisoners to manage any issues raised. The aim is to provide appropriate
support to encourage prisoners to cease self-isolating. The policy instructs that
prisoners who self-isolate should be monitored daily by staff with weekly isolation
reviews.
58. When Mr Zmijewski began self-isolating, staff correctly opened a self-isolation log
and spoke to him to understand his motivation for doing so. Mr Zmijewski said that
he feared for his safety at Maidstone due to prisoners believing he had been an
informer whilst at The Mount. Initially, Maidstone took appropriate steps to try to
investigate his concerns but found no evidence to suggest that Mr Zmijewski had
experienced any issues while at The Mount. However, following this, staff made
little effort to re-engage with Mr Zmijewski or explore any other possible motives for
his self-isolation. An entry in the self-isolation log stated that Mr Zmijewski may
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have been self-isolating in an attempt to obtain a transfer to another prison, closer
to his family. There is, however, no record of this being discussed with him.
59. Although wing staff were aware that Mr Zmijewski had chosen to self-isolate, he
was still attending church services and some appointments without an officer
escort, as well as asking to be unlocked from his cell to attend wing association,
where he was seen chatting with his peers. It is possible that this contributed to the
inconsistent use of the self-isolation log. Staff made no entries in the log after 30
August and the weekly self-isolating review that should have taken place on 4
September did not. A review might have enabled staff to either close the log or
further explore his concerns and put in place appropriate measures to support Mr
Zmijewski.
60. Mr Zmijewski’s self-isolation log should have been overseen by a case manager,
who would have been responsible for ensuring that relevant partner agencies were
appropriately informed and engaged. Mr Zmijewski’s self-isolation was discussed at
three weekly SIM meetings. However, the meeting minutes and interviews with staff
indicated that little update was given in regard to his condition and other
departments such as the mental health team were not appropriately informed or
able to offer their support. The Head of Safety could not tell us why more detailed
updates were not provided at the SIM. Additionally, the Head of Healthcare told us
that he expected healthcare staff to review every isolating prisoner on a daily basis.
He was unaware that Mr Zmijewski was self-isolating.
61. In the weeks prior to his death, staff interactions with Mr Zmijewski were minimal
and, as a result, there were few opportunities to properly assess the risk he posed
to himself. No attempts were made to effectively engage with him. The isolation log
we reviewed lacked detail and forward planning, contained very few details about
the issues that had been identified and it did not address how staff would
encourage Mr Zmijewski to end his self-isolation. There was no evidence of
collaboration between prison staff and partner agencies, that wing staff contributed
to the log on a daily basis, or that a SO reviewed it weekly. Regular, thorough self-
isolation reviews, meaningful conversations and documented daily checks may
have identified possible risk factors to suicide and self-harm and alerted staff when
Mr Zmijewski’s risk increased. We make the following recommendation:
The Governor and Head of Healthcare should ensure that:
• plans for isolating prisoners contain detailed information about
identified risks and agreed actions to reduce or end isolation,
• prison staff regularly review plans and ensure that any changes are
recorded and actioned; and
• healthcare staff review and document the mental state of a self-
isolating prisoner at least once a week.
Key work
62. In common with many other prisons, the key work scheme is not operating as it
should at Maidstone. During the month of Mr Zmijewski’s death, 64% of scheduled
key worker sessions were completed. However, there was no record of Mr
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Zmijewski being offered or attending any key work sessions during the three
months he was there. Mr Zmijewski’s allocated key worker told us that he had
offered Mr Zmijewski key work sessions on three occasions. On two of these, Mr
Zmijewski declined the session and the third time, he asked to speak with a SO,
which was subsequently actioned. The key worker told us that he did not document
any of these as he was a new officer and was not yet familiar with the computer
system. He confirmed that he now knows how to navigate the prison system and
records all his key worker entries.
63. In addition, the Head of Residence told us since Mr Zmijewski’s death, prisoners
who are self-isolating are automatically placed on a CSIP (Challenge, Support and
Intervention Plan) to provide them with additional support. In light of this change
and the key work support Mr Zmijewski was offered, we make no recommendation.
Clinical care
64. The clinical reviewer concluded that Mr Zmijewski’s physical healthcare was of a
reasonable standard and was equivalent to that which he could have expected to
receive in the community. He did however find that the mental healthcare Mr
Zmijewski received could have been improved.
65. When Mr Zmijewski self-referred to the mental health team on 27 June, his request
was triaged, and an appointment was made for him to see the GP the following
week. When Mr Zmijewski failed to attend this appointment, another appointment
was made which he again failed to attend. The clinical reviewer found no clear
documentation detailing the reason why Mr Zmijewski did not attend these
appointments.
66. Although it is always possible that Mr Zmijewski had made an informed decision to
decline further engagement with mental health services, the clinical reviewer found
that the possibility of his non-attendance being attributable to a deterioration in his
mental state could not be excluded. The Head of Healthcare will want to consider
the clinical reviewer’s recommendation to review local procedures relating to non-
attendance, specifically when there is evidence of a mental health related concern.
Emergency response
67. When the officer found Mr Zmijewski ligatured in his cell, he did not radio a code
blue, check for signs of life or start CPR. At interview, he explained that, as a new
officer, he had recently completed his first aid training and felt competent and
comfortable in what he should do in the event of a medical emergency. He said,
however, that dealing with a medical emergency in training was very different to
experiencing a medical emergency in reality. He said that when he found Mr
Zmijewski unresponsive, he was in a state of shock and confusion and, as a result,
did not follow correct procedures.
68. We recognise that the officer was faced with an extremely distressing situation and,
as a new officer, had likely not been exposed to such difficult situations before.
Although prison emergency procedures were not fully followed, we find that he
acted with the best intentions while in a heightened state of emotion and shock. He
immediately entered the cell, raised the alarm and cut the ligature. Staff responded
within a minute and an ambulance was quickly requested so that the delay to Mr
12 Prisons and Probation Ombudsman
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Zmijewski’s treatment was minimal. The officer said that he has learnt from the
death of Mr Zmijewski and told us what he would do differently should he be faced
with a similar emergency situation. The Governor may wish to consider how best to
support staff, particularly those who are new, to effectively implement their training
in emergency situations.
Prisons and Probation Ombudsman 13
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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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