Rolandas Karbauskas

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Rolandas
Karbauskas, a prisoner at HMP
Lowdham Grange, on 25 March
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 Rolandas Karbauskas was found hanged in his cell on 25 March 2023 at HMP
Lowdham Grange. He had been there only five days. He was 49 years old. I offer my
condolences to Mr Karbauskas’s family and friends.
Mr Karbauskas’ death was the third of three self-inflicted deaths at Lowdham Grange in
March 2023. HM Inspectorate of Prisons and the Independent Monitoring Board expressed
concerns about the safety of the prison around the time of Mr Karbauskas’ death. In
February 2023, the management of the prison transferred from Serco to Sodexo and
resulted in a reduction of staff levels, higher levels of drugs, violence, self-harm, less time
out of cells and a deterioration in staff-prisoner relationships. In May 2024, the
management of Lowdham Grange transferred to HMPPS.
Mr Karbauskas was at HMP Lincoln for approximately a year before he arrived at
Lowdham Grange. Problems had occurred at both prisons, and it is clear how isolated and
unhappy Mr Karbauskas had become. He did not speak English and staff efforts to use
interpreting services were inconsistent. Towards the end of his life, Mr Karbauskas
willingly spoke about his problems and said he had not been able to tell anybody because
of the language barrier.
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 February 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 12
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Summary
Events
1. On 19 March 2022, Mr Rolandas Karbauskas was remanded to HMP Lincoln
charged with murder. On 11 November, he was sentenced to life imprisonment. Mr
Karbauskas was from Lithuania and did not speak English.
2. Mr Karbauskas arrived at Lincoln with a Suicide and Self-Harm (SASH) warning
form. Staff in reception at Lincoln did not document whether they had seen it. It said
Mr Karbauskas was very depressed, exhibiting bizarre behaviour and had been
subject to intermittent observations. Aside from the information on the SASH form, it
was also Mr Karbauskas’ first time in prison. Staff did not record whether they had
considered starting suicide and self-harm monitoring procedures, known as ACCT.
3. A reception nurse referred Mr Karbauskas to the mental health team, but they had
not made arrangements to see him. When the open referral came to light six
months later at a multi-disciplinary (MDT) meeting, the mental health team closed
the referral without anyone seeing him first or telling him that he had been
discharged from the service.
4. Mr Karbauskas received very few keywork sessions at Lincoln. Those which took
place involved other prisoners being used to interpret and on other occasions staff
decided that his lack of engagement was down to him not wanting to speak to them.
Officers failed to document whether they had used telephone interpreter services.
5. On 20 March 2023, Mr Karbauskas transferred to HMP Lowdham Grange. The
reception nurse used another prisoner to interpret and referred Mr Karbauskas to
the mental health team. An officer also carried out an interview and used a prisoner
to interpret.
6. A mental health nurse tried to assess Mr Karbauskas. He could not understand Mr
Karbauskas and had not arranged an interpreter for the appointment despite the
notes confirming he did not speak English. The nurse used hand gestures to
communicate and told a colleague he would need to rebook the appointment using
a translation service. He did not do so, and Mr Karbauskas was never assessed.
7. At approximately 9.45am on 25 March, an officer failed to complete the welfare
checks when unlocking the prisoner cells. At approximately 10.30am, a prisoner
found Mr Karbauskas ligatured by a shoelace attached to the bunk above him. He
raised the alarm. Prison and healthcare staff attended and carried out
cardiopulmonary resuscitation (CPR).
8. Paramedics arrived and at 10.55am, confirmed that Mr Karbauskas had died.
Findings
9. There were omissions in the care Mr Karbauskas received during his brief period at
Lowdham Grange, and during the year he spent at Lincoln.
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10. At Lincoln, the mental health team failed to action the mental health referral and
they discharged him from the mental health service without seeing him or telling
him. Keywork sessions were few and never utilised appropriate interpreting
services.
11. At Lowdham Grange, prisoners were used to interpret, and a mental health
assessment was not carried out because the nurse had not arranged an interpreter
and did not rebook the appointment.
12. An officer failed to carry out a welfare check at unlock as he should have done.
Recommendations
• The Governor and Head of Healthcare at HMP Lincoln should:
• review processes to ensure staff consider PERs and SASH forms and record
that they have done;
• conduct a regular audit to satisfy themselves the process is embedded; and
• ensure staff know the red flags for suicide and self-harm and, where they are
present, document their reasoning for not starting ACCT procedures.
• The Governor at HMP Lincoln and Director at HMP Lowdham Grange and their
Heads of Healthcare should audit of the use of interpreting services to assure
themselves that they are always used where appropriate, and if they are not ensure
all staff are trained in their use.
• The Clinical Matron at HMP Lincoln should ensure that prisoners are not discharged
from the mental health service without ever being seen face to face and that they are
informed of the decision.
• The Director at HMP Lowdham Grange should ensure that staff understand they
should complete a welfare check at unlock and consider randomised checks of
CCTV footage to ensure they are being done.
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The Investigation Process
13. HMPPS notified us of Mr Karbauskas’s death on 25 March 2023.
14. The investigator issued notices to staff and prisoners at HMP Lowdham Grange
informing them of the investigation and asking anyone with relevant information to
contact her. A prisoner from Lowdham Grange contacted the IMB, who in turn
contacted the investigator and she interviewed him. Another prisoner wrote a letter
to tell us he had helped to translate for the reception nurse.
15. The investigator visited Lowdham Grange on 4 April 2023. She obtained copies of
relevant extracts from Mr Karbauskas’ prison and medical records.
16. The investigator interviewed six members of staff and a prisoner in Lowdham
Grange in April and August 2023. She also interviewed three members of staff from
HMP Lincoln by video conference in July 2023.
17. NHS England commissioned a clinical reviewer to review Mr Karbauskas’ clinical
care at the prison. She conducted joint interviews with the investigator.
18. We informed HM Coroner for Nottingham City of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
19. The Ombudsman’s office tried to contact Mr Karbauskas’ family to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
20. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Lowdham Grange
21. HMP Lowdham Grange is a Category B male adult prison located in Lowdham,
Nottinghamshire. The prison was operated by Serco for 25 years but on 16
February 2023, Sodexo took over the running of the prison. This was the first time a
prison had transferred from one private provider to another. Nottinghamshire
Healthcare NHS Foundation Trust provides healthcare services.
22. In December 2023, HMPPS took over management of the prison on an interim
basis, but in May 2024, the prisons minister announced that HMPPS would take
over permanently.
HM Inspectorate of Prisons
23. The most recent full inspection of HMP Lowdham Grange was in May 2023.
Inspectors reported that the prison was not safe, with high levels of drug use and
violence. The transfer from Serco to Sodexo had led to uncertainty and anxiety
among prisoners and staff, with significant numbers of key and specialist staff
leaving.
24. The restricted regime put in place during the COVID-19 pandemic had continued for
too long and although the new Director had quickly implemented a new regime, too
many prisoners had too little time out of their cell. Access to work and education
was poor and too little keywork was being delivered.
25. It found that although 11% of prisoners at Lowdham Grange were foreign nationals,
a key recommendation from their last report to provide professional telephone
interpreting and translated materials had not been achieved.
26. HMIP carried out an independent review of progress at the prison in January 2024.
They found that levels of violence had increased by 55% and self-harm by 41%
since the 2023 inspection. A high number of staff had resigned leaving the prison
desperately short-staffed. Inspectors did not find sufficient progress had been made
in a single one of the concerns raised in the full inspection.
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 January 2023, the IMB
reported that the safety of the prison had deteriorated. There had been an increase
in the number of prisoner-on-prisoner assaults, in self-harm and in weapons finds.
28. The Board considered that relationships between staff and prisoners had
deteriorated and there had been a significant reduction in purposeful activity which
had led to prisoners spending long periods locked in their cells. Healthcare services
continued to be under great pressure and the IMB considered that physical and
mental healthcare was at a lower standard to that in the community.
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29. The Board issued an addendum to their annual report covering the period 1
February to 31 March 2023. The management and operation of the prison passed
from Serco to Sodexo on 16 February 2023. The Board noted serious concerns
relating to the operation of the prison and implications for safety over the next six to
seven weeks. The number of prisoners on ACCT more than doubled, from 13 to 32,
between the end of February and the end of March. A significant number of staff
had left since the change in contract was announced in August 2022. IMB members
had noticed low staffing levels on all wings.
Previous deaths at HMP Lowdham Grange
30. Mr Karbauskas was the eighth prisoner to die at Lowdham Grange since March
2020. Of the previous deaths, two were from natural causes, two were drug related,
and three were self-inflicted. There are no similarities between the findings in this
investigation and previous investigations. Mr Karbauskas’ death was also the third
of three self-inflicted deaths that occurred in March 2023. By the end of 2023, there
had been two more self-inflicted deaths at the prison. As a result of these self-
inflicted deaths, Lowdham Grange is receiving additional support and monitoring
from regional and national safety teams.
HMP Lincoln
31. HMP Lincoln is a Category B prison, which predominantly serves the courts of
Lincolnshire. It holds remanded and convicted adult/young adult male prisoners.
Nottingham Healthcare NHS Foundation Trust provides health services and there is
24-hour nursing cover.
HM Inspectorate of Prisons
32. The most recent inspection of HMP Lincoln was in December 2019 to January
2020. Inspectors reported that Lincoln was a much safer prison since their last
inspection in 2017, though there had been two self-inflicted deaths since then.
Inspectors said that the prison’s approach to prisoners in crisis was good, and they
had implemented previous PPO recommendations. The inspectors found that
prisoners and staff had a good relationship, which was a real strength.
Independent Monitoring Board
33. In its latest annual report, for the year to 31 January 2023, the IMB reported that the
number of ACCT documents opened had decreased by 34% from the previous
reporting year and self-harm incidents by 28%.
34. Most IMB applications related to a variety of healthcare management issues. There
was a recognised shortage of staff.
Keywork
35. The keyworker 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
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settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework.
36. 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.
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Key Events
37. On 19 March 2022, Mr Rolandas Karbauskas was remanded to HMP Lincoln
charged with murder. On 11 November, was sentenced to life imprisonment for
murder and received a minimum term of 18 years. Mr Karbauskas was Lithuanian
and did not speak English. This was his first time in prison.
HMP Lincoln
38. Mr Karbauskas arrived with a Suicide and Self-Harm (SASH) warning form which
had been completed that day by ‘Person A’. No one at Lincoln was able to clarify
who this person was or where they were based. It is possible she was a member of
escort staff, or someone based at the court.
39. Person A had ticked certain boxes on the SASH form indicating Mr Karbauskas
seemed very depressed and was exhibiting bizarre behaviour or signs of mental
disorder. At some point before arriving at Lincoln, he was subject to intermittent
observations, but it is unclear exactly when. Person A also noted that Mr
Karbauskas was very evasive when it came to answering questions about self-
harm, behaved strangely, did not make eye contact and had not been eating while
withdrawing from alcohol. She noted that HMP Lincoln had been informed but did
not record by what method this had happened.
40. On reception, an officer noted in Mr Karbauskas’ prison record that Mr Karbauskas
had been assessed as unsuitable to share a cell. The prison record contains no
reference to the SASH form or whether any consideration was given to beginning
suicide and self-harm prevention procedures (known as ACCT).
41. The Reception nurse noted that she used the telephone interpreting service
‘Language Line’ to help her carry out the reception screen. She made no reference
to a PER (Person Escort Record, which accompanies the individual from police
custody to court and to prison and records details about risk), the SASH form or if
she considered starting suicide and self-harm prevention procedures (known as
ACCT). She referred Mr Karbauskas to the alcohol intervention service and noted a
doctor would assess him that evening. (Lincoln was unable to provide the
investigator with a copy of Mr Karbauskas’ PER.)
42. Another nurse also saw Mr Karbauskas in reception. It is unclear if he used an
interpreting service. He noted that Mr Karbauskas seemed low, but said he had no
current thoughts of suicide or self-harm. He recorded that Mr Karbauskas had taken
an overdose the year before and spent time (unknown exactly when) in a Lithuanian
psychiatric hospital. Mr Karbauskas said he was depressed and would like to be
referred (presumably to mental health services).
43. The nurse noted Mr Karbauskas was not on an ACCT, but that it was his first time
in prison. He made no mention of the SASH form but noted he had seen the PER.
He referred Mr Karbauskas to the mental health team.
44. A GP at the prison saw Mr Karbauskas that day and used the telephone interpreting
service. She noted his alcohol intake, that he denied any mental health issues but
said he had tried to drown himself in a lake 18 months beforehand. She made no
reference to whether she had considered starting ACCT procedures.
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45. On 23 March, a mental health nurse made four phone calls to Mr Karbauskas (via
the in-cell phone) to arrange his mental health assessment. She received no reply
and did not rebook the appointment. SystmOne (the electronic medical record) has
nothing in place to flag when referrals are left unresolved.
46. While Mr Karbauskas was at Lincoln, staff noted issues communicating with him
because of the language barrier. It is not clear what staff, including keyworkers, did
to try and properly address the communication problem. Staff did not document
whether they had used the formal interpreting services and, although another
prisoner was used on one occasion, that prisoner’s language was Russian, not
Lithuanian. Keyworkers, on occasion, noted that Mr Karbauskas did not want to
engage (although it is not clear how they established that). Mr Karbauskas received
12 keywork sessions during his time at Lincoln.
47. On 30 September, a healthcare administrator recorded in Mr Karbauskas’ medical
record that on 29 September, healthcare staff held a multi-disciplinary team meeting
to discuss allocations. A nurse, a therapist, a neurodiversity practitioner and a
senior forensic psychologist attended the meeting. They noted that Mr Karbauskas
had an open mental health referral from March 2022. The open referral came to
light after an administrative data cleanse.
48. The healthcare administrator recorded that the MDT attendees had noted that the
pharmacist saw Mr Karbauskas every day for medication (for back pain) and that
the physiotherapist, and a GP had also seen him. The mental health referral did not
contain information about the reasons for the referral and wing staff, other clinicians
and Mr Karbauskas had not raised any issues since. The MDT attendees agreed
there was no rationale to see him and decided to close the referral and discharge
him from the mental health caseload without any further investigation.
49. On 11 November, Mr Karbauskas received a life sentence with a minimum of 18
years imprisonment. He was not assessed by healthcare staff on his return from
court as he should have been.
HMP Lowdham Grange
50. On 20 March 2023, Mr Karbauskas transferred to HMP Lowdham Grange.
51. A nurse completed Mr Karbauskas’s reception screen and asked another prisoner
to interpret. Mr Karbauskas told her that he had been depressed for a while but had
not been able to tell anybody because of the language barrier. He wanted to work
with the mental health team and have some medication to help him with what he
described as ‘daily struggles’. He said he had always had an issue with his mental
health, but he denied any thoughts of suicide or self-harm. The nurse referred him
to the mental health team.
52. Later that day, a Prison Custody Officer (PCO) took Mr Karbauskas to E wing and
carried out what he described as an induction keyworker session. He asked another
prisoner from C wing who spoke Lithuanian to interpret. Mr Karbauskas said that he
was happy to be at Lowdham Grange and felt safe there. He said he had no history
of self-harm or suicide attempts (although he had told staff at Lincoln that he did).
He said he was looking forward to making a fresh start and he hoped to make
positive and progressive steps towards his sentence plan. He expressed an interest
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in employment and education. The PCO told him that he could use the Kiosk or in-
cell technology to apply for positions. Mr Karbauskas assured him that that
everything else was fine and the PCO said if anything else arose he should not
hesitate to approach a member of staff.
53. A prisoner mentor (a prisoner who fulfils a support role for other prisoners)
introduced himself to Mr Karbauskas. He spoke a few words of Lithuanian and
asked if he could help with anything. Mr Karbauskas appeared timid but showed Mr
Davis his artwork. The next day, the mentor gave him some colouring pencils as Mr
Karbauskas’ had almost worn out. (On another day, he helped Mr Karbauskas order
his canteen and add his brother’s telephone number to the system.)
54. Also on 21 March, an officer made an entry on NOMIS (electronic prisoner record)
for the chaplain. She wrote:
‘The Quaker Chaplain. Mr Karbauskas can speak no English at all. I spent a great
deal of time trying to get an interpreter but there were no staff to collect a Lithuanian
prisoner. An officer told me that there are a number of Lithuanian prisoners on
Houseblock 4, and he felt it would be wise if he could be moved to Houseblock 4 as
soon as possible. I saw him, and he is Christian. He has put his name down as RC.’
55. On 22 March, a foreign national representative at Lowdham Grange saw Mr
Karbauskas on Houseblock 2 to assist with his induction. Other staff were present
and, as they had a one-off issue getting through to the interpreting service, a
seconded officer fluent in Lithuanian was used to interpret. She asked Mr
Karbauskas if he needed a foreign national phone code to be set up to call his
family abroad, but he said that he was only in contact with his brother (who lived in
Lincoln) and his solicitor as he was appealing against his conviction. She checked
with the public protection team for any restrictions and offered him a phone call to
his brother, but his brother declined the call.
56. During the induction, Mr Karbauskas was also asked if he had any substance
misuse issues and he said not since he came into custody, however he disclosed
that he suffered from depression and anxiety, but that his medication had not been
sorted out at Lincoln. Another attendee at the meeting referred him to the mental
health team.
57. Mr Karbauskas said that he liked to work, so he was offered ESOL (English for
Speakers of Other Languages) classes. He also said that he had not eaten much,
and he was assisted with logging his menu and any phone numbers he needed.
58. On 23 March, a manager asked a mental health nurse to see Mr Karbauskas. When
he got to the wing, a PCO told him that Mr Karbauskas was a foreign national with
very limited English and that he required interpreting services.
59. At interview, the nurse said he asked Mr Karbauskas how he was, and he replied,
‘No English’. He asked him if he was okay, and Mr Karbauskas said he was. He
then tapped the side of his own head and said to Mr Karbauskas, ‘Are you mental?’,
to which Mr Karbauskas said, ‘I am not.’ The nurse made an arm cutting gesture
with his hand, and Mr Karbauskas said, ‘No, no, no.’
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60. The nurse said Mr Karbauskas’ cell was clean and so was Mr Karbauskas. He
asked an officer on the wing how they were managing to communicate with him,
and the officer said they were using another Lithuanian-speaking staff member.
61. The nurse said he told the Mental Health Matron an interpreter was needed for the
assessment. He noted in Mr Karbauskas’ medical record that he had seen Mr
Karbauskas on the wing and that his English was limited. He also noted that an
interpreter would be required, but that Mr Karbauskas reported no concerns and
that he had not identified any risks. The nurse noted he planned to rebook the
appointment using the telephone interpreting service, but there is no evidence that
he did this.
62. On 24 March, the prisoner mentor saw Mr Karbauskas again. Mr Karbauskas
indicated he had not taken any dinner because he had indigestion. The mentor
gave him some coffee, biscuits and fruit.
Events of 25 March
63. At 6.45am, we are told staff carried out the routine check on the wing. This check
was not captured on the CCTV footage given to the investigator which started later
when the unlock began. The prison was unable to retrospectively provide the
footage proving the check was done as there was a technical issue when the
management of the prison transferred from one company to another.
64. At 9.47am, a PCO started the wing unlock. She unlocked the cell doors but did not
look in on the prisoners or make any contact with them, contrary to policy.
65. At 10.14am, a member of works staff checked the inundation port on Mr
Karbauskas’ cell door, but the observation flap was shut so he would not have seen
into the cell.
66. At 10.29am, the prisoner mentor went to Mr Karbauskas’s cell and found him lying
on the bottom bunk. A towel was hung over the end of the bed slightly obstructing
his view, but he could see a ligature (a shoelace) around Mr Karbauskas’ neck
attached to the bunk above.
67. The prisoner mentor touched Mr Karbauskas and he was cold. He called for staff
and pressed the cell bell.
68. At 10.30am, two PCOs got to the cell and at 10.31am one of them called a code
blue (indicating a prisoner is unconscious or having breathing difficulties). They
started CPR while Mr Karbauskas was still on the bed and did not remove the
ligature around his neck.
69. At 10.33am, a nurse and other staff arrived. The nurse advised they move Mr
Karbauskas outside of the cell and, at that point, noticed rigor mortis was present.
They removed the ligature from around his neck and a PCO continued with CPR.
70. At 10.34am, staff in the control room called an ambulance and at 10.53am,
paramedics arrived. Paramedics tried to insert an airway but could not as Mr
Karbauskas’s tongue and swollen and his jaw had locked. They stopped CPR
attempts and confirmed his death at 10.55am.
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Contact with Mr Karbauskas’ family
71. On 25 March, the prison appointed a Family Liaison Officer. She visited Mr
Karbauskas’ brother, but he was not home and could not get back quickly. She
broke the news of Mr Karbauskas’ death to his brother’s wife.
72. Mr Karbauskas’ body was repatriated to Lithuania to be buried and the prison
contributed to the costs in line with national policy.
Support for prisoners and staff
73. After Mr Karbauskas’ 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.
74. The prison posted notices informing other prisoners of Mr Karbauskas’ 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 Karbauskas’ death.
Post-mortem report
75. The post-mortem report concluded Mr Karbauskas died as a result of hanging.
There were no significant toxicological findings.
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Findings
76. Across the two prisons, Lincoln and Lowdham Grange, a number of opportunities to
help Mr Karbauskas were missed. Poor reception processes, infrequent key
working, inappropriate clinical decisions, and a missed welfare check all
contributed. The ability of staff at both prisons to effectively recognise Mr
Karbauskas’ risk was impacted significantly by one thing – the failure to consistently
use appropriate interpreting services. Subsequently, Mr Karbauskas was isolated
and suffering mentally, but this was never adequately addressed.
Assessment of risk on arrival at HMP Lincoln
77. Mr Karbauskas arrived at Lincoln with a number of risk factors. He was charged
with murder and was in prison for the first time, and he had a history of mental ill-
health, including suicide attempts. According to the SASH form, he had been
monitored via intermittent observations, seemed very depressed and was exhibiting
bizarre behaviour. A note on the form said staff at Lincoln had been informed before
his arrival but there is nothing in the record to indicate this or that anyone
considered the information in the SASH form.
78. The Head of Healthcare at Lincoln said healthcare staff would normally receive
suicide and self-harm related information on new arrivals and then redirect the
information to the mental health team. The clinical matron was also asked how such
information was dealt with and she said any communication of this nature was
usually emailed by the court liaison and diversion team to the prison who then
redirected it to mental health. Whoever picked up such information should tell the
mental health crisis nurse and the reception nurse. This did not happen in Mr
Karbauskas’ case.
79. The records suggest that not all reception staff saw the SASH form, and only some
appeared to have seen the PER (which could not be provided to the PPO). There is
no evidence that anyone in reception at Lincoln considered starting ACCT
procedures, although a nurse noted that he was not on an ACCT. (The nurse also
referred him to the mental health team.)
80. We consider that there was sufficient information about Mr Karbauskas’ risk of
suicide and self-harm to indicate ACCT monitoring was required for a period of
time, to allow him to settle and staff to assess his wellbeing.
81. The clinical reviewer concluded that the care Mr Karbauskas received at Lincoln
was not equivalent to what he could have expected to receive in the community.
82. We recommend:
The Governor and Head of Healthcare at HMP Lincoln should:
• review processes to ensure staff consider PERs and SASH forms and
record that they have done;
• conduct a regular audit to satisfy themselves the process is embedded;
and
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• ensure staff know the red flags for suicide and self-harm and, where
they are present, document their reasoning for not starting ACCT
procedures.
Use of interpreting services at HMP Lincoln and HMP Lowdham Grange
83. Prison Service Instruction (PSI) 07/2015, Early days in custody, says that
Governors must ensure that all information is made available in an accessible
format and in a range of languages reflecting the make-up of the local prison
population, so that all prisoners understand the range of services that are available
to them.
84. Mr Karbauskas was Lithuanian and did not speak English. (As of June 2023,
Lithuanians made up four percent of the total prison population in England and
Wales, but owing to their locations, Lincoln and Lowdham Grange are likely to have
a significantly higher population of Lithuanians.) The records show instances of staff
noting this and using telephone interpreting services or other staff to interpret.
There are also instances where staff failed to use any appropriate means to
communicate with him, and instead they used other prisoners and hand gestures.
When Mr Karbauskas was invited to communicate through proper channels, he was
eager and able to tell staff he was suffering mentally.
85. Both Lincoln and Lowdham Grange are equipped with telephone interpreting
services and staff told us they were mostly easy and effective to use. Despite this,
in Mr Karbauskas’ case, use of the telephone service was inconsistent. Lincoln and
Lowdham Grange should work with staff to find out why and take steps to address
this. We make the following recommendation:
The Governor at HMP Lincoln and Director at HMP Lowdham Grange and their
Heads of Healthcare should audit of the use of interpreting services to assure
themselves that they are always used where appropriate, and if they are not
ensure all staff are trained in their use.
86. We were also made aware that the Kiosk at Lowdham Grange displayed
information in English when Lithuanian was selected. The Director will wish to
address this immediately.
Key work at Lincoln
87. Mr Karbauskas only had 12 keywork sessions at HMP Lincoln. The investigator
asked Lincoln’s keywork lead about this low input. He said that each prisoner
should receive 45 minutes once a week, but that at the time Mr Karbauskas was
there, they were only hitting 18.4% of the keywork target. At the time of the
interview, the rate had improved, but only to 26.3%.
88. Although some of the gaps can be accounted for when Mr Karbauskas had his trial,
input was still significantly below the target. Lincoln has since introduced a personal
officer scheme alongside the keyworker scheme. All officers are now encouraged to
employ a ‘first fix’ approach whereby they attempt to solve prisoners’ issues rather
than always refer them to a keyworker (which arguably should be the role of every
prison officer as standard, so it remains to be seen whether badging it as a personal
officer scheme makes a difference to staff behaviour).
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89. The quality of the keywork sessions that did take place was problematic. Officers
did not attempt to use interpreting services and instead either too quickly concluded
that Mr Karbauskas did not want to engage or tried to use other prisoners to
interpret. It is not appropriate to use other prisoners to interpret when the
conversation may be of a sensitive nature.
90. The investigator asked the keywork lead for his opinion of the keywork entries, and
he said his impression was also that Mr Karbauskas did not want to engage. The
investigator pointed out that, in fact, he had engaged well when a proper
interpreting service was used or other officers who spoke Mr Karbauskas’ language.
91. The keywork lead confirmed that there were no barriers to staff using the telephone
interpreting service and that appropriate rooms and telephones are readily
available.
Mental and clinical healthcare at Lincoln
92. After a nurse made a mental health referral, an agency nurse made four attempts to
call Mr Karbauskas using the in-cell phone, but he did not answer, and the
assessment was not rebooked. The clinical matron said that the nurse should have
visited Mr Karbauskas in his cell to find out why he was not picking up his phone
and complete the assessment face to face.
93. The referral remained open for six months until the matter was identified and
discussed at an MDT, but no one assessed Mr Karbauskas in person. At the
meeting, a collective decision was made to close the referral and discharge him
from the service because there was no evidence he had since come into contact
with the service or that anyone had raised any concerns about him. Staff failed to
tell Mr Karbauskas he had been discharged from the service.
94. The clinical matron told us that they now have an administrator who conducts audits
to identify open referrals that have not been dealt with. We are satisfied that,
completed regularly, that system should detect any anomalies, however, no one
should be discharged from the service without being seen or told. We make the
following recommendation:
The Clinical Matron at HMP Lincoln should ensure that prisoners are not
discharged from the mental health service without ever being seen face to
face and that they are informed of the decision.
95. In November 2022, Mr Karbauskas received a life sentence and was not assessed
when he returned from the court. The Head of Healthcare said that officers had
often taken newly sentenced prisoners straight to the wing rather than ensuring they
were seen by healthcare staff as directed by national policy. He had been in contact
with the prison’s Safety Lead to ensure officers were made aware that such
prisoners must be brought through Reception where they would be offered an
assessment. We are content with this arrangement and do not make a
recommendation.
14 Prisons and Probation Ombudsman
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Mental and clinical healthcare at HMP Lowdham Grange
96. The clinical reviewer did not find the care Mr Karbauskas received in his five days at
Lowdham Grange equivalent to what he could have expected to receive in the
community.
97. When Mr Karbauskas first arrived at Lowdham Grange, a nurse inappropriately
asked another prisoner to translate for her. Mr Karbauskas said he had been
depressed for a while, but the language barrier had stopped him telling anybody.
However, he denied thoughts of suicide and self-harm, so the nurse referred him to
the mental health team and did not consider opening an ACCT.
98. The investigator spoke to the physical health matron and the area healthcare lead.
Both agreed that using other prisoners to interpret healthcare interactions was not
appropriate. They were less sure if the reception area had the right facilities to use
a telephone interpreter and did not think that staff inductions covered it. We have
since established that there is a suitable room and telephone in reception.
99. On 23 March, an agency mental health went to see Mr Karbauskas following a
nurse’s referral. The agency mental health nurse could not understand Mr
Karbauskas and communicated largely by hand signals. He noted in Mr
Karbauskas’ medical record that an interpreter would be required for an
assessment but did not book one. The record was very clear that Mr Karbauskas
could not speak English, so he should have known that an interpreter was needed.
Wing staff have also confirmed that there was a room and phone that the nurse
could have used.
100. As we have already made a recommendation to the Head of Healthcare at
Lowdham Grange about the proper use of interpreting services, we make no further
recommendation here.
Welfare checks at HMP Lowdham Grange
101. PSI 75/2011 says: ‘The appropriate arrangements will depend on the local regime,
but there need to be clearly understood systems in place for staff to assure
themselves of the well-being of prisoners during or shortly after unlock. Where
prisoners are not necessarily expected to leave their cell, staff will need to check on
their well-being, for example by obtaining a response during the unlock process.’
102. On 25 March, an officer did not carry out a welfare check when she unlocked each
cell door before moving onto the next. She was a psychology student on a year’s
placement at Lowdham Grange but had left by the time the PPO carried out
interviews.
103. In the officer’s absence, the investigator spoke to the wing Custodial Operations
Manager. She said that although she would personally open a prisoner’s door after
it had been unlocked, she did not believe it was mandatory. As noted above, this is
not in line with prison policy and suggests that correct procedures are not widely
understood at Lowdham Grange. We make the following recommendation:
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The Director at HMP Lowdham Grange should ensure that staff understand
they should complete a welfare check at unlock and consider randomised
checks of CCTV footage to ensure they are being done.
Director to note
104. When staff responded to the prisoner mentor’s call for help, they quickly began
CPR. However, the two first officers on scene did not remove the ligature from Mr
Karbauskas’ neck rendering any first aid redundant. The Director will wish to
consider whether there is any learning from the emergency response in this case.
Inquest
An inquest into Mr Karbauskas’ death concluded on 7 February 2025 that his death was
suicide due to self-inflicted ligature asphyxiation.
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