Przemyslaw Wozniak

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Przemyslaw
Wozniak, a prisoner at
HMP Wandsworth, on 17
February 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
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© Crown copyright, 2024
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to
any cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Przemyslaw Wozniak was found hanged in his cell at HMP Wandsworth on 17
February 2021. He was 34 years old. I offer my condolences to Mr Wozniak’s family and
friends.
Mr Wozniak, a Polish national, was detained under a European Arrest Warrant and had
appealed against the decision to extradite him to Poland. As far as we know, his appeal
was still outstanding at the time of his death.
We are concerned that Mr Wozniak’s mental health was not properly assessed, despite
him referring himself for mental health support seven times while he was in prison. We
consider that a doctor missed a further opportunity to assess Mr Wozniak’s mental health
and wellbeing on 12 February, shortly before he died. We are also concerned that this
important information about a possible deterioration in Mr Wozniak’s mental wellbeing was
not shared with prison staff.
Mr Wozniak gave no indication that he was at imminent risk of suicide. However, we are
very concerned that there is no evidence that staff had any meaningful interaction with Mr
Wozniak for the last 11 months of his time at Wandsworth, and that there appears to have
been no recognition that the continued uncertainty about his possible extradition may have
been a risk factor for suicide, particularly given the very restricted regime during the
pandemic. Without regular engagement with prisoners, staff are unlikely to be able to pick
up on changes in mood and behaviour that may indicate increased risk.
This version of my report, published on my website, has been amended to remove the
names of the staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman December 2021
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 13
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Summary
Events
1. On 23 December 2019, Mr Przemyslaw Wozniak, a Polish national, was remanded
to HMP Wandsworth to await extradition, after being arrested under a European
Arrest Warrant.
2. The day after his arrival at Wandsworth, Mr Wozniak was referred to the mental
health in-reach team, who concluded that his mental health needs could be met by
the primary care mental health team. The primary care team assessed Mr Wozniak
on 3 January 2020 and concluded that he was not depressed and had no other
enduring mental health problems.
3. Mr Wozniak’s key worker spoke to him regularly until 13 March, when key work was
suspended due to the pandemic. There is no record of officers checking Mr
Wozniak’s welfare after that before Mr Wozniak’s death nearly a year later. There
is no record that anyone used interpreting services to speak to Mr Wozniak while he
was at Wandsworth.
4. Mr Wozniak self-referred to the mental health in-reach team seven times between
February 2020 and February 2021. He was not seen in person by the in-reach
team, except on the seventh occasion on 4 February 2021 when a mental health
nurse conducted a welfare check on him. The nurse agreed that a GP appointment
would be made to review Mr Wozniak’s mood.
5. On 12 February, a prison GP visited Mr Wozniak’s cell to review his mood, as well
as a case of sinusitis. The doctor prescribed ibuprofen for Mr Wozniak’s sinusitis
but did not ask him about his mood. He said he had no concerns about Mr Wozniak
and described his presentation and behaviour during the assessment as “normal”.
6. At around 3.32pm on 17 February, two officers were delivering meals to Mr
Wozniak’s wing, and found Mr Wozniak hanging in his cell. One of the officers
immediately raised a general alarm.
7. At about 3.35pm, several officers arrived at Mr Wozniak’s cell, including a custodial
manager who immediately radioed a medical emergency ‘code blue’ (indicating a
life-threatening situation). Two of the officers began cardio-pulmonary resuscitation
(CPR).
8. Around a minute later, two nurses arrived and took over the CPR. Paramedics
arrived at around 3.44pm but were unable to revive Mr Wozniak. They pronounced
him dead at 4.25pm.
Findings
Mental healthcare
9. Mr Wozniak self-referred to the mental health in-reach team seven times. We
agree with the clinical reviewer that after the third referral, the in-reach team should
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have considered why Mr Wozniak’s needs were not being met, rather than
reviewing each referral on its own merits.
10. We consider that that this important information about Mr Wozniak’s possible
mental health concerns should have been shared with prison staff to ensure they
were aware of all information that might affect Mr Wozniak’s risk to himself,
especially during the pandemic.
11. When Dr A reviewed Mr Wozniak in person on 12 February 2021, he relied too
heavily on what Mr Wozniak said and did not consider that he had specifically been
asked by the in-reach team to review Mr Wozniak’s mood. The clinical reviewer
found that that the doctor’s failure to ask Mr Wozniak about his mood fell
considerably short of the expected practice and was not in line with NICE guidance
on the identification of depression in adults. It was also a missed opportunity to
assess Mr Wozniak’s mental health shortly before his death and to consider
whether he needed support.
Management of risk of suicide and self-harm
12. We are very concerned that there is no evidence that staff checked Mr Wozniak’s
welfare or had any meaningful interactions with him during the 11 months before his
death.
13. We are also concerned that no one appears to have recognised that the continuing
uncertainty about his possible extradition may have been a risk factor for Mr
Wozniak.
Emergency response
14. The officer who found Mr Wozniak hanging raised a general alarm, rather than
using the medical emergency code. This led to confusion about the nature of the
incident and whether healthcare staff were required and a three-minute delay in
calling an ambulance. Such delays could be critical in life-threatening emergencies.
Recommendations
• The Head of Healthcare and the Mental Health Services Manager should:
• ensure their operational policy on repeated referrals to the mental health in-
reach team includes guidance on repeated self-referrals; and
• ensure that healthcare staff share information that may be relevant to a
prisoner’s risk of suicide or self-harm with prison staff.
• The Head of Healthcare should ensure that a copy of this report is shared with Dr A,
and that his employing agency discusses the Ombudsman’s findings with him.
• The Governor and Head of Healthcare should ensure that staff use appropriate
interpretation services when discussing complex matters with prisoners with limited
English language skills.
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• The Governor should ensure that:
• all prisoners receive regular wellbeing checks during the restricted pandemic
regime, in line with the Exceptional Delivery Model and that these are recorded
on NOMIS;
• staff understand the importance of having regular, meaningful conversations
with prisoners to identify changes in appearance, behaviour or mood that may
indicate increased risk; and
• there are regular wellbeing checks on prisoners subject to possible extradition or
deportation to assess whether their risk to themselves has changed.
• The Governor should ensure that staff understand the importance of calling the
appropriate medical emergency code promptly.
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The Investigation Process
15. The investigator issued notices to staff and prisoners at HMP Wandsworth
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
16. The investigator obtained copies of relevant extracts from Mr Wozniak’s prison and
medical records.
17. The investigator interviewed eleven members of staff at Wandsworth. The
interviews were completed by video link and telephone due to the restrictions
imposed as a result of the COVID-19 pandemic.
18. NHS England commissioned a clinical reviewer to review Mr Wozniak’s clinical care
at the prison. The majority of the interviews were conducted jointly by the clinical
reviewer and the investigator.
19. We informed HM Coroner for London Inner West of the investigation. The coroner
provided us with the report of the post-mortem examination. We have sent the
coroner a copy of this report.
20. We wrote to Mr Wozniak’s next of kin (in Polish) to explain the investigation and to
ask if they had any issues that they wanted the investigation to consider. We have
not received any questions from the family, and they have not requested a copy of
this report.
21. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not identify any factual inaccuracies. Their action plan is annexed to
this report.
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Background Information
HMP Wandsworth
22. 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. Oxleas 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
23. The most recent inspection of HMP Wandsworth was conducted in March 2018.
Inspectors noted that 38% 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 mental health team each month. They reported
that healthcare was reasonably good and that healthcare staff used telephone
interpreting services reasonably well.
24. 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.
25. HMIP also 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. All isolating
prisoners told HMIP that they felt well supported by staff.
26. HMIP reported that primary mental health applications had increased due to
prisoners’ anxieties about their health and regime restrictions, but these were
managed creatively through in-cell assessment forms, work packs and health
information leaflets. HMIP found that there was a large number of foreign national
prisoners at the prison and those who were not fluent in English were not as well
informed about pandemic arrangements.
Independent Monitoring Board
27. 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 2020, the IMB were
impressed by the prison’s speedy response to the COVID-19 pandemic but were
concerned that the aging and cramped accommodation could no longer meet
prisoners’ needs. The IMB reported that the prison’s key worker scheme had been
suspended due to the pandemic, but that it had been replaced by welfare checks.
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The IMB reflected that the primary mental health team received multiple referrals
every day, but that the majority were seen within 48 hours.
28. The IMB found that the Prison Service system used to support prisoners at risk of
suicide or self-harm (known as ACCT) was often compromised by operational
constraints. In particular, they were concerned that little effort was made to use
interpretation services to ensure that foreign national prisoners understood what
was happening, although they noted that special in-cell packs had been developed
for foreign national prisoners to occupy them during lockdown.
Previous deaths at HMP Wandsworth
29. Mr Wozniak was the ninth prisoner to die at Wandsworth since February 2019. Of
the previous deaths, four were from natural causes, one was drug-related and three
were self-inflicted. There were no notable similarities in these cases to the death of
Mr Wozniak, although we have not yet completed our investigation into one of the
self-inflicted deaths.
30. Since Mr Wozniak’s death, there have been a further five self-inflicted deaths at
Wandsworth, all of which are currently being investigated by the Ombudsman.
European Arrest Warrant (EAW)
31. 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)
32. 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. 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 multidisciplinary review meetings involving the prisoner.
33. 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. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011, Safer
Custody.
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Key worker scheme
34. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners and helping people
settle into life in prison. Under the scheme all prisoners in the male closed estate
must be allocated a key worker whose responsibility is to engage, motivate and
support them through the custodial period, and who is expected to spend an
average of 45 minutes per prisoner per week on the key worker role, including
individual time with each prisoner.
35. The key worker scheme was suspended across the prison estate during the
pandemic, although prisons were expected to put regular welfare checks in place
for vulnerable prisoners (such as those considered to be at risk of suicide or self-
harm). In COVID-19 Operational Guidance – Exceptional Regime & Service
Delivery (version 3), issued on 3 April 2020, HMPPS said:
“It is more vital than ever that we make sure that residents are safe. Staff should be
briefed to use all the interactions that are possible in this period of regime
restrictions and social distancing to check on welfare, taking any opportunity to
communicate hope and encourage self-care, as well as to identify any change in
appearance or behaviour that gives rise to concerns about raised risk of self-harm
or suicide. Each resident should be seen at least once each day, and it is good
practice to record that this has occurred (there may not be time for this to be done
on an individual basis, but a landing or wing record may be possible).”
36. Later advice in the COVID-19 Gold Briefing addendum said:
“For [prisoners other than the most vulnerable] there is no requirement as to how
often a wellbeing check has to take place but depending on the availability of staff it
is recommended that where possible they take place on a weekly basis. The details
of the wellbeing check should be recorded on NOMIS [prisoners’ electronic records]
where possible.’’
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Key Events
37. Mr Przemyslaw Wozniak, a Polish national, was facing serious charges in his home
country, including fraud, robbery and theft. On 23 December 2019, he was arrested
on a European Arrest Warrant and taken to Westminster Magistrates Court for an
extradition hearing. After the court hearing, he was remanded to HMP
Wandsworth.
38. Mr Wozniak told the reception nurse at Wandsworth that he had no thoughts or
history of harming himself and had not seen a doctor in recent months. He said he
had been prescribed antidepressants in Poland but did not have a GP in the UK.
He also had Crohn’s disease (a life-long inflammatory bowel condition) for which he
was prescribed medication.
39. In his secondary health screen the next day, Mr Wozniak told healthcare staff that
he took clonazepam (for short-term management of anxiety/panic attacks) and
gabapentin (pain relief) while in Poland, but had not taken clonazepam since
Summer 2019. Healthcare staff referred Mr Wozniak to the mental health in-reach
team.
40. On 27 December, the in-reach team reviewed Mr Wozniak’s case records for the
first time. They noted that he heard voices telling him, “Hate you,” but that he had
no thoughts of self-harm. They concluded that Mr Wozniak’s mental health needs
could be met by the primary care mental health team.
41. On 3 January 2020, Nurse A from the primary care mental health team assessed
Mr Wozniak in person. Mr Wozniak told the nurse that he was hearing voices
saying, “I don’t like you” and that he had difficulty sleeping. The nurse concluded
that Mr Wozniak was not depressed and had no other enduring mental health
problems. She also noted that the voices Mr Wozniak was experiencing were
‘pseudo hallucinations’ (a vivid sensory experience which the person recognises as
unreal, in contrast to a ‘true’ hallucination which is perceived as real) and gave him
an information pack to help manage his symptoms. She told Mr Wozniak that his
referral was now closed but explained how to contact the primary care team in
future if he needed to.
42. Later that day, Mr Wozniak met his key worker, Officer A, for the first time. Key
work sessions with the officer continued until 13 March, when all key working was
stopped at Wandsworth due to the COVID-19 pandemic. In interview, the officer
told us that Mr Wozniak did not want to go back to Poland and his impending
extradition was the reason he was “depressed”, although he did not record this on
NOMIS. The officer also told us that Mr Wozniak was “doing great” and was happy
in his job as a painter on the wings. The officer said he had no concerns about Mr
Wozniak’s behaviour or presentation during his time as his key worker.
43. On 2 February, the in-reach team reviewed Mr Wozniak’s case records for the
second time after Mr Wozniak self-referred to them. He wrote, “Hi can I pleas (sic)
apoitment (sic) I need to talk thanks.” The in-reach team concluded again that Mr
Wozniak’s mental health needs could be met by the primary care team.
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44. On 24 February, Mr Wozniak came back from exercise with cuts and bruises on his
face but told staff he was fine. He was examined by a nurse but refused to speak to
the violence reduction representative. (In interview, Officer A told us that, as far as
he was aware, Mr Wozniak did not have any debts and was not a victim of bullying.)
45. The next day, the in-reach team reviewed Mr Wozniak’s case records for the third
time following another self-referral in which he wrote, “Hi can I pleas (sic) go talk
with consulta (sic).” This time they decided that Mr Wozniak should be reviewed by
the GP. The GP appointment, which was due to take place on 29 February, did not
happen due to an incident in the prison which meant that only prisoners with urgent
needs were seen in their cells. There is no evidence that the missed appointment
was followed up.
46. On 2 March, the in-reach team reviewed Mr Wozniak’s case records for the fourth
time after he self-referred to them again. Again, the in-reach team decided that he
should be reviewed by a GP. On 9 March, Mr Wozniak failed to attend his
scheduled GP appointment. There is no evidence to explain why he did not attend,
although he apologised two days later and asked for another appointment, which
was scheduled for 19 March.
47. On 19 March, the GP visited Mr Wozniak’s cell because he had not attended his
appointment, but Mr Wozniak was not available.
48. Mr Wozniak attended court (in person or by video link) in connection with his
extradition on five occasions (in December 2019, and January, February, March
and April 2020). On 16 April, the court ordered Mr Wozniak’s extradition to Poland.
He applied for permission to appeal the extradition order; however, his application
was halted temporarily pending the outcome of a related appeal. (As far as we
know, Mr Wozniak was still awaiting a decision when he died ten months’ later.)
49. On 5 June, an Assistant Psychologist assessed Mr Wozniak’s suitability to
participate in mental health group activities. Mr Wozniak explained that he wanted
to attend but not to speak. According to his records, Mr Wozniak did not participate
in any group activities while at Wandsworth.
50. On 16 July, the substance misuse team, CGL (‘Change Grow Live’), conducted a
clinical records review and noted that Mr Wozniak had previously reported a history
of occasional alcohol use, sometimes with clonazepam and other illicit drugs. Mr
Wozniak completed an in-cell work pack which was provided by CGL but left some
sections blank due to his poor English.
51. On 18 September, Mr Wozniak was allowed a telephone call from his brother to tell
him that their mother had died. A member of the prison’s chaplaincy team recorded
on Mr Wozniak’s electronic prison record that Mr Wozniak seemed to take the news
well. Staff were informed and a chaplaincy welfare check was conducted on Mr
Wozniak. No further concerns were raised about this issue. (There is no evidence
to suggest that Mr Wozniak asked for or was offered or received any bereavement
support following his mother’s death.)
52. Between April and September, staff found ‘hooch’ (illicitly brewed alcohol) in Mr
Wozniak’s cell three times. In October, he was punished with 14 days in the
segregation unit. A nurse assessed Mr Wozniak in the segregation unit and
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concluded he was mentally and physically fit to be segregated. Mr Wozniak told the
nurse that he had no thoughts of suicide or self-harm.
53. On 19 October, the in-reach team reviewed Mr Wozniak’s case records for the sixth
time after he self-referred to them while in the segregation unit. Mr Wozniak wrote,
“Hi can I ask appointment thanks.” In response, the in-reach team recorded the
following on Mr Wozniak’s electronic medical record (known as ‘SystmOne’): “Not
for in-reach at the minute; can be re-referred if necessary.”
2021
54. On 4 February 2021, the in-reach team reviewed Mr Wozniak’s case records for the
seventh time following another self-referral in which he wrote, “Hi I feel sick.” The
in-reach team agreed to arrange a welfare check on him. Nurse B, a mental health
nurse, conducted the welfare check later that day. Mr Wozniak told the nurse that
he was feeling upset and that he may have “depression and [be] misunderstood.”
He said his sleep was poor, but the nurse did not think he appeared to be sleep-
deprived. Mr Wozniak also told the nurse that he had no thoughts of suicide or self-
harm. The nurse planned to ask a GP to review Mr Wozniak’s mood.
55. On 9 February, Dr B, telephoned Mr Wozniak’s cell in order to review his mood, but
Mr Wozniak hung up when the doctor asked to speak to him. The doctor rebooked
the appointment for three days’ time.
56. On 12 February, Dr A, a locum GP who regularly works at Wandsworth, visited Mr
Wozniak’s cell to review his mood, as well as to treat possible sinusitis. The doctor
told us in interview that he prescribed ibuprofen for Mr Wozniak’s sinusitis but did
not ask him about his mood because Mr Wozniak did not mention it. He told us that
he had no concerns about Mr Wozniak and described his presentation and
behaviour during the assessment as “normal”.
57. On 13 February, Mr Wozniak made a telephone call to a friend where he discussed
employment when he was released from prison. (The call was translated from
Polish to English by staff at Wandsworth at the investigator’s request.) Mr Wozniak
called another friend the next day, but his friend was busy.
17 February 2021
58. At 11.17am, Mr Wozniak made a telephone call to an unknown number. The
duration of the call was only three seconds. He also sent some letters for posting; it
is not known who they were addressed to.
59. At around 11.43am, an officer unlocked Mr Wozniak’s cell door and he left his cell
to collect his lunch. Mr Wozniak returned to his cell around three minutes later
carrying a plate of food.
60. At around 11.51am, Officer B locked Mr Wozniak’s cell door. A minute or so later,
she checked Mr Wozniak’s cell as part of her midday roll check and raised no
concerns.
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61. At around midday, the in-reach team reviewed Mr Wozniak’s case records for the
eighth and final time following his seventh self-referral in which he wrote, “Hi I am
disable (sic). I feel pain and upset. I am feeling long lasting stress I have difficult
sleep can you take my in appointment thanks.” The in-reach team decided that the
GP should review Mr Wozniak again.
62. At around 3.30pm, the Learning and Skills Manager, went to Mr Wozniak’s cell to
return a workbook of his which she had marked. (The workbook was from PACT
[Prisoners & Their Affected Families], who provide family relationship services to
prisoners.) In interview, the Learning and Skills Manager, told us that she knocked
on Mr Wozniak’s door, opened the cell observation panel and called out to him.
She did not receive a response and could not see anything in the cell as it was
dark, so she slid the envelope under Mr Wozniak’s door and walked away. She told
us she had no concerns about his welfare and did not see or hear anything
suspicious.
63. At around 3.32pm, Officer B and Officer C were delivering the evening meals to B
Wing, with assistance from two prisoners. Officer C opened Mr Wozniak’s cell door,
shouted “Dinner”, and moved to the next cell.
64. Officer B, who was walking behind Officer C, looked into Mr Wozniak’s cell and saw
him suspended by cloth material tied around his neck, connected to the rail of his
privacy curtain. She immediately called out to Officer C and went into Mr Wozniak’s
cell, followed by Officer C.
65. Officer C raised a general alarm over the radio. (In interview, she could not recall
exactly what she said.) Officer C pulled out her ‘fish knife’ to cut Mr Wozniak down
but could not reach him, so she held his legs to support his weight. Officer B stood
on a chair to try to cut Mr Wozniak down but still could not reach the ligature, so
also supported his weight until help arrived. Two other officers responded quickly to
the general alarm and one of them managed to cut the ligature. When Mr Wozniak
was cut down, however, he fell on top of Officer C. Custodial Manager (CM),
Supervising Officer (SO) A and other officers arrived at the cell very shortly
afterwards.
66. At about 3.35pm, the CM went into the cell and immediately radioed a medical
emergency ‘code blue’ (indicating a prisoner is not breathing or is having difficulty
breathing). SO A started cardio-pulmonary resuscitation (CPR), with another officer,
and ordered all other staff out of the cell. In interview, the SO told us that as a
general alarm was raised rather than a code blue, the responding officers were
confused about the nature of the emergency. A prisoner had assaulted an officer
on the wing around half an hour before, which the SO believed had added to the
sense of confusion. The SO also said there was a lot of screaming and general
panic.
67. Around a minute later, Nurse D and Nurse E arrived and took over CPR from the
SO. More healthcare staff arrived a few minutes later. At interview Nurse E also
commented on the initial confusion. He said the alarm went off and the control
room put out a message on the net saying, whistle’ (alarm) on B wing, and then that
was followed by screaming, and then that was followed by a call for medical
assistance, and then that was followed by a code blue, hanging.
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68. Paramedics arrived at around 3.44pm but were unable to revive Mr Wozniak. They
pronounced him dead at 4.25pm.
Contact with Mr Wozniak’s family
69. At 5.15pm on 17 February, SO B telephoned who he believed was Mr Wozniak’s
brother, but who later turned out to be his cousin. The SO broke the news of Mr
Wozniak’s death over the phone to his cousin, helped by Officer D, who acted as an
interpreter.
70. At 11.55am on 18 February, Mr Wozniak’s cousin provided contact details for Mr
Wozniak’s brother who lived in Belgium. SO B telephoned Mr Wozniak’s brother
straight away, again assisted by Officer D, to explain the circumstances of his
brother’s death. Wandsworth maintained contact with Mr Wozniak’s family, and in
line with national instructions, offered to contribute to the costs of the funeral.
Support for prisoners and staff
71. At around 5.00pm on 17 February, a senior manager held a debrief with prison staff
involved in the emergency response. All staff and prisoners were offered the
support of the prison’s care team.
72. The prison posted notices informing other prisoners of Mr Wozniak’s death and
offering support.
Post-mortem report
73. A post-mortem examination identified Mr Wozniak’s cause of death as hanging.
Post-mortem toxicology tests found no traces of illicit drugs, apart from nicotine.
74. The pathologist noted that Mr Wozniak had tested positive for COVID-19 but that
this had not contributed to his death.
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Findings
Mental healthcare
Referrals to mental health in-reach team (in-reach team)
75. Mr Wozniak was first referred to the in-reach team at his secondary health
screening on 24 December 2019. Between 2 February 2020 and 17 February
2021, he self-referred a further seven times. (None of Mr Wozniak’s referrals
specifically mentioned self-harm or suicide.) Despite his repeated self-referrals, Mr
Wozniak was not seen in person by the in-reach team, except on the seventh
occasion on 4 February 2021 when Nurse B conducted a welfare check on him.
76. The Service Manager for the Mental Health Service at Wandsworth, told us in
interview that mental health referrals are discussed and triaged at a daily
multidisciplinary referral meeting, using the clinical records available, and a record
of the outcome is recorded on the prisoner’s SystmOne (electronic medical record).
77. The mental health team’s operational policy on repeated referrals from primary care
services says:
“If there are three rejected referrals from primary care in a three-month
period then the duty worker attends the Primary Care Complex Case
Meeting to discuss and agree a plan of care.”
The policy does not say whether this includes self-referrals.
78. The Service Manager for Mental Health told us in interview that if someone referred
themselves on three occasions and they were all rejected by Mental Health for not
being suitable, they would complete a welfare check, but she said that this would
not apply to people who had already been seen and assessed by other clinicians,
as Mr Wozniak had.
79. The clinical reviewer concluded that, on its own individual merits, the response to
each referral was appropriate to the level of symptoms Mr Wozniak was reporting.
However, she considered that the whole picture was not fully considered in relation
to the repeated self-referrals. She considered that there needs to be a balance
between what is practical to achieve in a prison and what would meet individual
patient need. She considered that after more than three referrals, action should
have been taken to review why Mr Wozniak’s needs remained unmet. This could
have taken the form of an exceptional decision for the in-reach team to review him
in person and/or a multidisciplinary case review to discuss his ongoing needs.
80. We share the clinical reviewer’s concern that Mr Wozniak’s multiple self-referrals
could have indicated an unmet need. We agree with the clinical reviewer’s
conclusion that the in-reach team should have considered Mr Wozniak’s history of
self-referral as a whole, rather than individually, which might have highlighted that
he needed additional support. We are particularly concerned at the impact of the
very restricted pandemic regime on prisoners’ mental health. We agree with the
clinical reviewer that it was an omission not to review Mr Wozniak’s mental health
needs, given his repeated self-referrals.
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81. We are also concerned that there is no evidence that healthcare staff told prison
staff that Mr Wozniak had made repeated mental health self-referrals. We consider
that this information should have been shared so that prison staff could make an
informed assessment of Mr Wozniak’s risk to himself.
Dr A’s assessment of Mr Wozniak on 12 February
82. When Dr A visited Mr Wozniak in his cell on 12 February, we consider that he relied
too heavily on what Mr Wozniak said and did not consider that he had specifically
been asked by the in-reach team to review his mood. The clinical reviewer
considered that the doctor’s failure to ask Mr Wozniak directly about his mood or to
actively assess his mood that day did not meet even the most basic of clinical
guidance in relation to identifying depression.
83. We consider that Dr A’s failure to ask Mr Wozniak about his mood was a missed
opportunity to assess Mr Wozniak’s mental health shortly before his death. We
recognise that we cannot presume what the outcome of such an assessment would
have been and so cannot draw any conclusions about whether it would have
prevented Mr Wozniak’s death. Despite this, we consider it to be a very serious
omission.
84. For the reasons set out above, the clinical reviewer concluded that the clinical care
Mr Wozniak received did not always meet the required standard.
85. We make the following recommendations:
The Head of Healthcare and the Mental Health Services Manager should:
• ensure their operational policy in relation to repeated referrals to the
mental health in-reach team includes guidance on repeated self-referrals;
and
• ensure that healthcare staff share information that may be relevant to a
prisoner’s risk of suicide or self-harm with prison staff.
The Head of Healthcare should ensure that a copy of this report is shared
with Dr A, and that his employing agency discusses the Ombudsman’s
findings with him.
Management of risk of suicide and self-harm
86. PSI 64/2011, which governs suicide and self-harm prevention procedures, requires
all staff who have contact with prisoners to be aware of the risk factors and triggers
that might increase the risk of suicide and self-harm and take appropriate action.
Any prisoner identified as at risk of suicide or self-harm must be managed under
ACCT procedures.
87. We have considered whether staff at Wandsworth should have recognised Mr
Wozniak as at risk in the weeks and months leading up to his death and begun
ACCT procedures to support him.
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88. Mr Wozniak did not leave a suicide note and we do not know what caused him to
take his life. However, he had some risk factors for suicide and self-harm: he had a
history of mental health issues; he had been disciplined for illicitly brewing alcohol,
known as ‘hooch’; his mother had died in September 2020; he was facing
extradition to Poland where he faced further possible imprisonment; and he had
been waiting 10 months for a decision on his future.
Mr Wozniak’s extradition
89. 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.”
90. 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
nationals informed about their possible deportation. In this case it was for the court
and Mr Wozniak’s own lawyer to keep him updated about his appeal against
extradition. However, the effect on Mr Wozniak was likely to be very similar: he
apparently did not want to be extradited to Poland and he had spent 10 months
waiting to hear whether this was going to happen or not.
91. We are concerned that there is no evidence that anyone at Wandsworth considered
whether this might be having an effect on his mental wellbeing, especially given the
very restricted regime during the pandemic. There is also no evidence that his risk
was reassessed when he returned from attending court (whether in person or by
video link) as it should have been.
92. We are also concerned that there is no evidence that prison or healthcare staff ever
considered whether Mr Wozniak had any language difficulties. This is particularly
important in relation to his mental healthcare. Polish was Mr Wozniak’s first
language, and though he could speak and write in English to some extent,
explaining complex emotional and mental health needs in a language a prisoner is
not proficient in can lead to miscommunication. The record shows that Mr Wozniak
was unable to complete an in-cell work pack given to him by the substance misuse
service due to poor English. Yet there is no evidence that interpretation services
were ever used to speak to Mr Wozniak during his time at Wandsworth. We make
the following recommendation:
The Governor and Head of Healthcare should ensure that staff use
appropriate interpretation services when discussing complex matters with
prisoners with limited English language skills.
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Key working / meaningful interaction
93. Before the COVID-19 pandemic started in March 2020, Officer A, Mr Wozniak’s key
worker, met him very regularly and recorded that he was doing well in his prison
job. He said at interview that Mr Wozniak had also told him he was “depressed”
because he did not want to be extradited to Poland, and we think that he should
have recorded this as well. As it is, there is nothing in Mr Wozniak’s records to
show that anyone recognised that his potential extradition might be causing him
concern or distress.
94. Officer A’s last key work session with Mr Wozniak was on 13 March.
95. We were told by the Head of the Offender Manager Unit (OMU) and Head of
Residence for B Wing that the key worker scheme was halted at Wandsworth
during the pandemic due to problems with staffing. They said that there were points
during the pandemic where some very limited key work took place in line with the
national Exceptional Delivery Models (EDM), generally using the in-cell phones, for
those prisoners deemed priority (such as those subject to ACCT monitoring). These
interactions were recorded on NOMIS, but only a very limited number of prisoners
received this service.
96. We were told that on days when staff numbers were higher, wing staff were asked
to do ‘key work-style’ welfare checks on as many prisoners as possible. This would
include checking in with prisoners, seeing how they were and assisting with any
issues. We were told that these checks would also have been recorded on NOMIS.
However, this service was sporadic and reliant on staffing numbers. Later in the
pandemic, staff started completing NOMIS-recorded welfare checks on prisoners
assessed as more vulnerable.
97. Apart from a check by the chaplaincy team when Mr Wozniak’s mother died in
September 2020, there is no evidence that staff undertook or recorded any welfare
checks for Mr Wozniak after Officer A’s key work sessions stopped in March 2020.
98. There are only six entries in his prison record in the 11 months after that date: one
negative comment in May about suspected hooch; one positive comment in July
when he helped another prisoner move cells; one record that he had been told his
mother had died in September; and three Incentive and Earned Privileges (IEP)
warnings in April, September and October. The last of these entries was made on
14 October 2020 and was an IEP warning because Mr Wozniak and his then cell
mate had not removed pictures from their wall. There were no entries at all for the
last four months of Mr Wozniak’s life.
99. We are very concerned that there is no evidence that staff checked on Mr
Wozniak’s welfare or had any meaningful engagement with him during the
pandemic, apart from when his mother died in September. We recognise that he
never told anyone he was having suicidal thoughts and that, in that sense, staff
could not have known that he was at imminent risk of suicide. However, many
prisoners do not disclose suicidal thoughts explicitly and, unless staff are having
regular, meaningful contact with prisoners, they are unlikely to pick up on changes
in a prisoner’s appearance, behaviour or mood that might suggest he is at risk.
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100. In this case, as we have already said, healthcare staff had not shared important
information that suggested that Mr Wozniak was struggling mentally. However, we
consider it is essential that staff recognise that a prisoner’s risk may change over
time, especially during the pandemic, and that they should have been aware in
particular that Mr Wozniak’s risk might increase as his potential extradition
remained unresolved for so long.
101. We recommend:
The Governor should ensure that:
• all prisoners receive regular wellbeing checks during the restricted
pandemic regime and that these are that are recorded on NOMIS;
• staff understand the importance of having regular, meaningful
conversations with prisoners to identify changes in appearance,
behaviour or mood that may indicate increased risk; and
• there are regular wellbeing checks on prisoners subject to possible
extradition or deportation to assess whether their risk to themselves
has changed.
Emergency response
102. PSI 03/2013 requires prisons to have a medical emergency response code
protocol, which ensures that there is no delay in calling an ambulance in a life-
threatening emergency, and to ensure that that all staff understand their
responsibilities in a medical emergency.
103. Officer C could not explain why she used the general alarm, rather than a medical
emergency code blue, to communicate that there was a life-threatening medical
emergency when she found Mr Wozniak hanging (although we appreciate that this
would have been a shocking discovery). Three minutes elapsed between the
general alarm and a custodial manager radioing a code blue, when an ambulance
was called. Officers and nurses reported that the general alarm caused confusion
because staff did not understand the nature of the incident they were attending.
However, the clinical reviewer was satisfied that nurses responded quickly and
effectively as soon as the code blue was called.
104. We cannot say if the three-minute delay affected the outcome for Mr Wozniak, but
we know that even a short delay may be critical in a medical emergency. It is,
therefore, essential that communication is clear, so that all staff know the nature of
the emergency, healthcare staff know what equipment is required, and an
ambulance is called without delay. We make the following recommendation:
The Governor should ensure that staff understand the importance of calling
the appropriate medical emergency code promptly.
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Inquest
105. The inquest into Mr Wozniak’s death concluded on 20 January 2023, and recorded
a verdict of suicide.
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