Thomas Oleisky

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Independent investigation into
the death of Mr Thomas Oleisky,
a prisoner at HMP Wealstun,
on 11 September 2022
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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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 Thomas Oleisky died on 11 September 2022, four days after he was found with a
shoelace tied around his neck in his cell at HMP Wealstun. He was 32 years old. I offer my
condolences to Mr Oleisky’s family and friends.
Staff started suicide and self-harm prevention procedures (known as ACCT) for Mr Oleisky
on 5 September 2022, after he harmed himself. He told staff he was at risk from other
prisoners on B Wing as he owed them money for hooch (illegally brewed alcohol). He was
moved to the segregation unit at his request.
Two days later, when Mr Oleisky could not cope on the segregation unit, staff moved him
back to B Wing because there was nowhere else to move him. That afternoon, a family
member contacted the prison to say that Mr Oleisky had called his father to say goodbye
as he was going to end his life. Staff found him with a dressing gown cord around his neck,
but he was unharmed. He then made a cut to his wrist. Staff moved him to G Wing and
increased checks to four an hour. Around an hour later, an officer found Mr Oleisky
unresponsive with a shoelace tied around his neck and attached to the window. He was
taken to hospital but never regained consciousness and died four days later.
I am concerned about the decision to move Mr Oleisky back to B Wing, the location that
had triggered his initial act of self-harm. The decision appeared to have been taken
unilaterally by a prison manager. I consider that there should have been a multidisciplinary
discussion about the best location for Mr Oleisky.
While staff considered placing Mr Oleisky on constant supervision on 7 September, I am
satisfied that the decision to increase observations to four an hour was reasonable in the
circumstances.
The investigation found that while staff held multidisciplinary ACCT reviews and set
appropriate care plan actions, the care plan was not completed correctly which potentially
led to confusion about whether actions had been completed or were still outstanding.
This version of our report, published on our website, has been amended to remove the
names of staff and prisoners involved in our investigation.
Susannah Eagle
Deputy Prisons and Probation Ombudsman March 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 13
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Summary
Events
1. On 23 June 2022, Mr Thomas Oleisky was sentenced to 27 months in prison for
controlling and coercive behaviour and sent to HMP Doncaster. It was his first time
in prison. On 12 July, he was moved to HMP Wealstun.
2. On 2 September, staff found hooch (illegally brewed alcohol) in Mr Oleisky’s cell
and saw that he was under the influence of alcohol. They confiscated the hooch. On
4 September, Mr Oleisky barricaded himself in his cell and told staff that he was in
debt to other prisoners due to the hooch. Staff began violence reduction procedures
to support him.
3. On 5 September, Mr Oleisky told staff that he had swallowed some paracetamol
because he was at risk from other prisoners. When an officer left to get help, Mr
Oleisky cut his arm. Staff moved Mr Oleisky to the segregation unit at his request.
Staff also started suicide and self-harm monitoring (known as ACCT). Mr Oleisky
told staff that he was scared that he would be assaulted by other prisoners on B
Wing and had self-harmed to get off the wing. When Mr Oleisky arrived at the
segregation unit, staff checked him five times an hour but at the first case review,
the frequency of checks was reduced to one an hour.
4. Staff planned to keep Mr Oleisky in the segregation unit for 72 hours and then move
him to a different wing. However, Mr Oleisky became paranoid that prisoners from B
Wing were in the segregation unit and on 7 September, he said he could not cope
with another night on the unit (there was a prisoner there who was very noisy and
on a dirty protest). The only cell available to move Mr Oleisky to, was his old cell on
B Wing. Mr Oleisky said he would rather go there for one night than stay on the
segregation unit, so staff moved him back to B Wing.
5. At around 1.00pm, Mr Oleisky’s grandfather telephoned the prison to say that Mr
Oleisky had called his father to say goodbye as he was going to end his life. Staff
went to Mr Oleisky’s cell and found that he had tied his dressing gown cord round
his neck. He was unharmed. He then cut his wrist. Healthcare staff dressed and
then stitched his wound.
6. Staff held an urgent ACCT case review and considered placing Mr Oleisky under
constant supervision, but Mr Oleisky said he did not want this. Instead, they
increased staff checks to four an hour. At around 3.40pm, staff moved Mr Oleisky to
G Wing.
7. During an ACCT check at 4.35pm, an officer found Mr Oleisky unresponsive with a
shoelace tied round his neck, which he had also tied to the window. The officer
went into the cell, cut the ligature and then called a medical emergency code. Mr
Oleisky was taken to hospital but never regained consciousness and died there on
11 September.
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Findings
8. While staff held multidisciplinary ACCT case reviews and set appropriate care plan
actions, the care plan was not completed correctly which meant it was unclear
whether actions had been completed or were still outstanding. Also, some staff
were unaware that they had been allocated care plan actions.
9. We consider that the decision to reduce observations from five an hour to one an
hour, very soon after Mr Oleisky arrived in the segregation unit, was premature.
Also, consideration should have been given to increasing observations the next day
when Mr Oleisky’s behaviour deteriorated, and he appeared paranoid that prisoners
from B Wing were in the segregation unit. We are satisfied that the decision on 7
September not to place Mr Oleisky under constant supervision but on four checks
an hour instead was reasonable in the circumstances.
10. We are concerned that a prison manager in the segregation unit appeared to make
a unilateral decision to move Mr Oleisky back to B Wing, a location which had
triggered his initial act of self-harm. We consider that there should have been a
multidisciplinary discussion about the best location for Mr Oleisky.
11. We are concerned that the officer who found Mr Oleisky with the shoelace around
his neck on 7 September did not call an emergency code immediately. We accept
that this was a short delay but nevertheless, the code should have been called first,
before going into the cell and cutting the ligature.
12. The clinical reviewer found that Wealstun provided reasonable care to Mr Oleisky
for his substance misuse and mental health issues although she identified issues
with record keeping and information sharing.
Recommendations
• The Governor should ensure that staff manage prisoners at risk of suicide and self-
harm in line with policy guidance, in particular that they:
• fill out the ACCT care plan correctly so that it shows the date by which the care
plan action is due and when it has been completed;
• ensure that staff who have been allocated ACCT care plan actions are aware;
and
• set the appropriate level of observations in line with the prisoner’s risk.
• The Governor should ensure that where a prisoner on ACCT is moved from
segregation and there is a concern regarding a potential risk created by a return to
normal location, then wider consultation should be sought prior to the move taking
place and an ACCT review arranged as soon as possible.
• The Governor should ensure that staff are aware of their responsibilities during
medical emergencies and that staff who discover the emergency should call the
appropriate medical emergency code immediately.
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• The Head of Healthcare should ensure healthcare staff keep accurate and timely
records of significant contacts.
• The Head of Healthcare should ensure that significant information is shared
promptly between healthcare services and where appropriate with wider prison
staff.
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The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Wealstun informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
14. The investigator received copies of relevant extracts from Mr Oleisky’s prison and
medical records.
15. The investigator interviewed 16 members of staff during November and December
2022.
16. NHS England commissioned an independent clinical reviewer to review Mr
Oleisky’s clinical care at the prison. She jointly conducted interviews with the
investigator.
17. We informed HM Coroner for West Yorkshire of the investigation. We have sent the
Coroner a copy of this report.
18. The Ombudsman’s family liaison officer contacted Mr Oleisky’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. They
asked how Mr Oleisky’s risk was assessed and what measures were put in place to
try to keep him safe, which we have addressed in this report. They also raised
several issues that were outside the remit of our investigation, which we have
addressed in separate correspondence.
19. Mr Oleisky’s family received a copy of the initial report. They did not provide any
further comments or information which impacted on the report’s findings.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and requested a recommendation
be re-worded. This report has been amended.
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Background Information
HMP Wealstun
21. HMP Wealstun is a category C prison near Wetherby, West Yorkshire, which holds
more than 800 men. There are ten residential units and a segregation unit. Practice
Plus Group provides health care services.
HM Inspectorate of Prisons
22. The most recent inspection of HMP Wealstun was in October 2022. Inspectors
reported that the prison had reasonably good outcomes on all the healthy prison
tests apart from purposeful activity which was not sufficiently good. These results
indicated an overall improvement in the prison since the last inspection in 2019.
23. HMIP’s priority concerns included the high levels of self-harm and lack of any
strategy to combat the problems. Although the prison had a safer custody hotline,
for families and friends concerned about a prisoner’s wellbeing, calls made out of
hours were unanswered and there was no voicemail facility.
24. Inspectors’ overall impressions of health care was of professional, resilient staff
delivering essential services. However, they considered staffing to be extremely
constrained, with the small primary care and pharmacy teams carrying several
vacancies, which resulted in regular agency staff use.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 May 2022, the IMB reported
that their main concerns included the lack of time prisoners spent out of cells and
staffing shortages. They considered ACCTs to be well managed but that the new
ACCT process, introduced in 2021, seemed complicated and took a while to bed in.
The segregation unit was reasonably well maintained and, on the whole,
relationships between staff and prisoners on the unit appeared to be good.
Previous deaths at HMP Wealstun
26. Mr Oleisky was the second prisoner to die at HMP Wealstun since September
2020. There are no similarities between the findings in our previous investigation
and those following our investigation into Mr Oleisky’s death.
Assessment, Care in Custody and Teamwork
27. 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
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carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
28. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
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,
Management of prisons at risk of harm to self, to others and from others (Safer
Custody).
Segregation Unit
29. Segregation units (sometimes called Care and Separation Units) are used to keep
prisoners apart from other prisoners. This can be because they feel vulnerable or
under threat from other prisoners or if they behave in a way that prison staff think
would put people in danger or cause problems for the rest of the prison. They also
hold prisoners serving punishments of cellular confinement after disciplinary
hearings. Segregation is authorised by an operational manager at the prison who
must be satisfied that the prisoner is fit for segregation after an assessment by a
member of healthcare staff.
30. Segregation unit regimes are usually restricted, and prisoners are permitted to
leave their cells only to collect meals, shower, make phone calls and have a daily
period in the open air. A manager, a member of the chaplaincy team and a member
of the healthcare team should visit the segregation unit daily and speak to each
segregated prisoner to check their welfare. A doctor should visit at least every three
days and a registered nurse on the other days to assess the physical, emotional
and mental wellbeing of the prisoners and whether there are any apparent clinical
reasons to advise against continuing segregation.
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Key Events
31. On 23 June 2022, Mr Thomas Oleisky was sentenced to 27 months in prison for
controlling and coercive behaviour and sent to HMP Doncaster. It was his first time
in prison.
32. Mr Oleisky had a history of alcohol and drug misuse. When he arrived at Doncaster,
staff identified that he had alcohol withdrawal symptoms. He was prescribed
appropriate medication and monitored. He was also prescribed pain relief for back
pain following a fall a few weeks before. He told staff that he was prescribed
mirtazapine (an antidepressant) in the community. However, this was not
prescribed at Doncaster because of potential interactions with his pain medication
(both medications suppress breathing).
33. On 5 and 6 July, Mr Oleisky was assaulted by other prisoners and was taken to
hospital on both occasions. He told staff that he had been seeing a woman who
was connected to a gang which may have been the cause of the assaults.
HMP Wealstun
34. On 12 July, Mr Oleisky was moved to HMP Wealstun. A nurse booked a GP
appointment to review his back pain medication and he was prescribed co-codamol
in the meantime.
35. On 26 July, a prison GP prescribed dihydrocodeine in place of the co-codamol. He
prescribed duloxetine (for low mood and pain) and a five-day course of
promethazine (to treat anxiety and sleep issues).
36. On 27 July, following a self-referral by Mr Oleisky, a Drug and Alcohol Rehabilitation
Service (DARS) worker recorded that she had seen Mr Oleisky (although she told
us she probably saw him the day before). She spoke to him about ‘hooch’ (illicitly
brewed alcohol) as she was aware it was in the prison. Mr Oleisky agreed to attend
Alcoholics Anonymous (AA) for peer support and she added him to the waiting list.
Mr Oleisky told her he had dyslexia and she assisted him with a workbook.
37. On 4 August, a mental health nurse saw Mr Oleisky following his self-referral on 27
July. He said he was having negative thoughts and was struggling to sleep at night.
He wanted to go back on mirtazapine, and she told him to discuss it with a GP (he
did not put in an application to see a GP). She suggested he do some ‘anxiety work’
and use distraction material. She added Mr Oleisky to her caseload. (This would
normally mean reviewing the prisoner every fortnight, but the mental health team
was short staffed at the time.)
38. On 12 August, Mr Oleisky attended AA and engaged well, according to his new
DARS worker.
39. On 23 August, the DARS worker saw Mr Oleisky on the wing and introduced herself
officially as his DARS worker. They worked through an alcohol in-cell pack. He
agreed to keep an urge and trigger diary. He implied he was using substances and
she gave him advice about substance misuse.
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40. On 2 September, staff found hooch in Mr Oleisky’s cell and found that he was under
the influence of alcohol. A nurse saw Mr Oleisky, but no one informed the DARS
team. Staff downgraded him to the basic level of the Incentives and Earned
Privileges (IEP) scheme and put him on a disciplinary charge.
41. On 3 September, Mr Oleisky told a Supervising Officer (SO) that he felt low. He had
self-referred to the mental health team and to DARS but felt at a loss. She
contacted a nurse in the mental health team, who said he would see Mr Oleisky the
next day.
42. On 4 September, Mr Oleisky barricaded himself in his cell. He said he was in debt
over the hooch and wanted to move wings. The SO noted he seemed very unwell
and submitted a Challenge Support Intervention Plan (CSIP) referral. (A CSIP is
used to manage prisoners who pose a risk of violent behaviour with the aim of
encouraging more positive behaviour. It can also be used to support victims of
violence.)
43. The nurse visited Mr Oleisky in his cell for a welfare check, but Mr Oleisky declined
to engage.
5 September: ACCT opened and move to segregation unit
44. On 5 September, the Head of Residence carried out Mr Oleisky’s adjudication
following the hooch find. She suspended the punishment because Mr Oleisky
showed remorse and his behaviour had been out of character.
45. Later that morning, Mr Oleisky told an officer that people were trying to get him, and
he had swallowed paracetamol. He was very agitated and, when the officer went to
get help, Mr Oleisky cut himself. Staff restrained him for his own safety, and then at
around 11.30am, moved Mr Oleiskey to the segregation unit at his request.
46. A nurse carried out the segregation health screen (which assesses whether there
are any health reasons why the prisoner should not be segregated) and recorded
no concerns. A different nurse recorded that healthcare staff should check Mr
Oleisky once an hour.
47. An officer started suicide and self-harm monitoring (known as ACCT). The Head of
Residence completed the Immediate Action Plan and set observations at five an
hour (the standard frequency for prisoners entering the segregation unit on an
ACCT until their first case review.) Staff gave Mr Oleisky an in-cell phone and
reminded him about Listeners (prisoners trained by the Samaritans).
48. A member of the safer custody team carried out the assessment interview. Mr
Oleisky said he was frustrated and annoyed with his circumstances, felt
overwhelmed and needed some quiet time. He said that he struggled with
obsessive compulsive disorder, dyslexia and dyspraxia, was being assessed in the
community for autism and needed to be on a quieter unit. She noted that she would
speak to the mental health team and GP and consider relocation to another wing.
49. The same day, the Head of Residence held the first case review. A mental health
nurse attended. The member of the safer custody team and a Custodial Manager
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(CM) (who was managing the CSIP) did not attend but spoke to the Head of
Residence ahead of the meeting to give their thoughts.
50. Mr Oleisky said he was relieved to be off B Wing as this had triggered his self-harm.
He said he had never considered harming himself before but was so scared of
being assaulted on B Wing that he thought it was his only choice. He said that he
had been holding the hooch for other prisoners and was now at risk from them
because he had drunk it and then been caught with it. He said that he had drunk the
hooch because he had looked at a photo of his children, which made him sad as he
was estranged from them. He thought the segregation unit would give him the
opportunity to sleep and refresh but he knew it was a short-term solution and he
would be expected to leave.
51. The review team reduced observations to one an hour. They concluded that it was
not currently necessary to remove any items, including razors, from him. The Head
of Residence noted that Mr Oleisky would remain in the segregation unit for 72
hours, to enable him to sleep and engage with support services. She created a care
plan which included that the CSIP was in place, and for the mental health team to
work alongside DARS and Mr Oleisky to maintain contact with his family.
52. A CM created plans to support Mr Oleisky through the CSIP process and emailed
details of the named perpetrators on B Wing to security. She was due to review the
CSIP plan on 8 September, once Mr Oleisky had moved to a new location (probably
F Wing).
6 September
53. On 6 September, a CM carried out a wellbeing check in the segregation unit. She
noted that Mr Oleisky’s behaviour was erratic, agitated and anxious. He thought
there were prisoners near him from B Wing and described someone who was not
there who he said had been outside his cell and had keys. She assured Mr Oleisky
this was not the case. She called a mental health nurse and asked her to check on
Mr Oleisky.
54. The nurse went to see Mr Oleisky. He was concerned about who was in the cell
next to him and seemed paranoid. She did not document the incident on Mr
Oleisky’s medical record but told the clinical reviewer she had asked another nurse
to check Mr Oleisky’s observations.
55. Later that day, the Head of Residence held the second case review. A nurse and a
SO attended. The Head noted that Mr Oleisky said he felt safe in the segregation
unit but had not managed to get the sleep he expected due to the environment and
him worrying. He was vague about his worries but asked if he was returning to a
standard wing that day. She thought this might be one of the things worrying him.
56. The Head of Residence noted that Mr Oleisky continued to say he had no thoughts
of self-harm but said he could not guarantee he would not do so again. She
maintained observations at one an hour.
57. A nurse saw Mr Oleisky that day. He was agitated and said his heart was pounding.
She booked him a blood pressure appointment and planned to recheck in the
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afternoon. She tried to see him later, but he was very hostile so could not be
unlocked. He told her he felt physically better.
58. That night, Mr Oleisky behaved strangely and claimed he was talking to someone
called ‘Ratio’.
7 September
59. On the morning of 7 September, a prison manager held Mr Oleisky’s adjudication
hearing (for not following a lawful order prior to being taken to the segregation unit).
Mr Oleisky admitted the charge and the manager suspended the punishment.
60. Later that morning, an officer noted in the ACCT observations log that Mr Oleisky
had to be helped to his feet in the exercise yard after feeling unwell and had been
checked by a nurse.
61. Mr Oleisky was upset and tearful and told a SO repeatedly that he could not stay in
the segregation unit. He said he could not spend another night there and that he
was not coping. (There was a prisoner on the unit who was making a lot of noise
and on a dirty protest.)
62. The SO told the manager of the segregation unit that Mr Oleisky said he was
struggling to cope.
63. The manager found out that the cell on F Wing was not going to be ready until the
next day and that the only available cell was Mr Oleisky’s old cell on B Wing. The
SO told Mr Oleisky, who said that he would rather go back to B Wing temporarily
than stay in the segregation unit.
64. Later that day, a CM came down to the segregation unit and someone told her that
Mr Oleisky was being moved back to B Wing. She told the manager of the
segregation unit that she did not think he should be moved, particularly to B Wing,
as he would self-harm there. She said that the plan was to hold him in the
segregation unit for 72 hours (until 8 September) before considering F Wing as a
new location.
65. The manager of the segregation unit told her that Mr Oleisky had said he would
prefer to go to B Wing than stay in the segregation unit for another night. He was
moved to B Wing at around 12.10pm. The plan was for him to spend one night
there before being moved to F Wing.
Move back to B Wing
66. That afternoon, at approximately 1.00pm, Mr Oleisky’s grandfather called the prison
and told them that Mr Oleisky had contacted his father to say goodbye because he
was going to end his life. A member of the safer custody team alerted staff on B
Wing, who found Mr Oleisky with his dressing gown cord tied around his neck. Staff
called a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties) and a nurse attended. Mr Oleisky was
unharmed.
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67. After the incident, an officer spoke to Mr Oleisky and encouraged him to tell his
family he was okay. She left the cell to give him some privacy, but he then cut his
wrist with a razor (she saw him do this through the observation panel). She called a
code red (a medical emergency code used for severe loss of blood) and the nurse
attended again. She dressed the wound but assessed that it needed stitches.
68. A SO held an ACCT case review which a nurse, a CM, the member from the safer
custody team and a manager attended. Mr Oleisky said he had not been sleeping
and did not know what was real anymore. He said he had told staff that he had
wanted to be moved back to B Wing so that he could hang himself.
69. The review panel considered whether to place Mr Oleisky under constant
supervision, but Mr Oleisky said he did not want this, and, over the course of the
review, his presentation became much calmer. Staff increased observations to four
an hour with staff expected to have three meaningful conversations with him a day.
Staff also decided Mr Oleisky should be moved to a cell on G Wing overnight before
moving to F Wing the next day. Staff decided that Mr Oleisky should have
supervised shaves but did not consider that any other measures, such as removal
of other items he could use to self-harm, were necessary. They considered that his
presentation had improved and there were enough other measures in place to keep
him safe.
70. A CM took Mr Oleisky to the healthcare unit to have his wound stitched. On the
way, he asked her if she could hear prisoners threatening him. She did not hear
anyone threaten him and tried to offer reassurance, but he said it felt very real.
They discussed his location, and he expressed an interest on the Residential
Support Unit on A Wing. She said staff would need to assess him.
71. After a nurse had stitched Mr Oleisky’s wounds, the CM took him to G Wing.
G Wing
72. At 3.40pm, the CM handed Mr Oleisky to an officer on G Wing. Mr Oleisky asked to
be locked in his cell because he did not like the noise on the wing and the officer
agreed. Staff checked on him at 3.45pm and there were no issues.
73. Around 20 minutes later, the officer took Mr Oleisky his bedding pack and had
another conversation with him. He asked if staff could bring him his meals as he did
not like the noise levels on the landings and got nervous around other people. She
agreed and he thanked her for everything she had done for him so far. She had no
concerns about his presentation.
74. At 4.10pm, an officer carried out a check and saw Mr Oleisky sitting on his bed
looking out of the window. At 4.25pm, the officer checked him again. Mr Oleisky
was slumped by the window in an odd position and the officer went into the cell. Mr
Oleisky had tied a shoelace around his neck and attached it to the window.
75. The officer cut the shoelace with his anti-ligature knife. He radioed a code blue at
4.26pm but was on the wrong channel so had to call it again. Staff in the control
room logged that they called the ambulance service at 4.27pm. The officer could
not find a pulse on Mr Oleisky’s wrist or neck so started chest compressions. Two
CMs took over when they arrived. Another member of staff brought a defibrillator.
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76. A nurse arrived at Mr Oleisky’s cell around six minutes after the officer called the
code blue. She assisted with resuscitation attempts by inserting an airway provided
by her colleague.
77. Paramedics arrived at the prison at 4.47pm and took over Mr Oleisky’s care. At
5.26pm, they left to take him to hospital.
78. Mr Oleisky did not regain consciousness and died in hospital at 12.30pm on 11
September.
Contact with Mr Oleisky’s family
79. On 7 September, the prison appointed a family liaison officer, and he telephoned Mr
Oleisky’s partner to tell her he was in hospital. He stayed in contact with the family
to offer support and advice. In line with national policy, the prison made a financial
contribution to Mr Oleisky’s funeral.
Support for prisoners and staff
80. After Mr Oleisky’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support. Welfare
checks were offered to relevant staff on 11 September and further debriefs were
held for staff who were on leave.
81. The prison posted notices informing other prisoners of Mr Oleisky’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Oleisky’s death.
Post-mortem report
82. The Coroner has provided the post-mortem report which concludes that Mr Oleisky
died from 1a) hypoxic brain injury 1b) cardiac arrest and 1c) hanging. Toxicology
tests were not carried out.
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Findings
Management of Mr Oleisky’s risk of suicide and self-harm
83. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures (known
as ACCT) that should be followed when a prisoner is identified as being at risk of
suicide and self-harm.
84. Staff started ACCT procedures on 5 September after Mr Oleisky cut himself. They
were still in place when he died.
85. We are content that staff opened the ACCT appropriately, that there were
multidisciplinary case reviews and that staff identified appropriate care plan actions.
86. However, we found that the care plan had been completed incorrectly which meant
that it was unclear whether actions had been carried out or were still outstanding.
Dates had been entered in sections where the status of the action (required or
completed) should have been recorded so it was unclear whether that was the date
an action was required, or the date completed. It is possible that anyone looking at
the care plan would have assumed the latter. We also note that a CM was unaware
that she had been allocated some actions. Clearly, it is very important that anyone
responsible for carrying out an ACCT care plan action is aware of what is required
and by when.
87. Staff set ACCT observations at five an hour when Mr Oleisky first arrived in the
segregation unit, which is the standard frequency of observations when a prisoner
is segregated, and an ACCT is opened. At the first case review later that day, staff
reduced observations to one an hour. We consider that observations were reduced
too quickly. Mr Oleisky had been in the segregation unit for only three hours at this
point. The Head of Residence told us that she was satisfied that Mr Oleisky’s risk
had reduced significantly following his move away from B Wing and to the
segregation unit, which had more staff available to keep him safe. However, Mr
Oleisky told staff at the first case review that he could offer no assurance that he
would not self-harm again. Given this, and Mr Oleisky’s very recent arrival in the
segregation unit, an environment that can be difficult for prisoners to cope with, we
consider that the reduction of observations to one an hour was premature.
88. At the second case review the next day, on 6 September, the review panel
maintained observations at one an hour. We note that staff were concerned about
Mr Oleisky’s erratic behaviour earlier that day and that he appeared to be paranoid
that prisoners from B Wing were in the segregation unit and near to his cell. At the
case review, he said he had not slept much as he was worried. Again, he said he
could not guarantee that he would not self-harm. While we accept that Mr Oleisky
had not self-harmed between the first and second case reviews, there were
concerns about increased paranoia and his general behaviour. We consider that
observations were set too low in the circumstances.
89. On 7 September, after his move back to B Wing, Mr Oleisky was found with a
dressing gown cord tied around his neck. The prison had been alerted that Mr
Oleisky had called his father to say goodbye as he intended to end his life. At the
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subsequent case review, the panel considered whether to place Mr Oleisky on
constant supervision. However, Mr Oleisky did not want this and instead, staff set
observations at four an hour. We consider this was reasonable in the
circumstances. Constant supervision can be oppressive for the prisoner and should
be used sparingly. Staff considered that the highest level of observations (four an
hour) was preferable, and we consider that this was a reasonable decision.
90. We note that staff did not remove any items, such as shoelaces or clothing, from Mr
Oleisky after he tied the dressing gown cord around his neck when he returned to B
Wing. It is a difficult judgement call as it can be distressing to prisoners to have
personal items removed and it should be reserved for prisoners at very high risk.
Staff told us that Mr Oleisky’s mood calmed significantly during the final case review
and apart from withholding razors, they did not consider that removal of any other
items was necessary given the frequency of observations in place and the move to
G Wing. We consider this was reasonable in the circumstances.
91. We recommend:
The Governor should ensure that staff manage prisoners at risk of suicide
and self-harm in line with policy guidance, in particular that they:
• fill out the ACCT care plan correctly so that it shows the date by which
the care plan action is due and when it has been completed;
• ensure that staff who have been allocated ACCT care plan actions are
aware; and
• set the appropriate level of observations in line with the prisoner’s risk.
Location
92. Mr Oleisky first self-harmed on 5 September and said he did this because he was
scared of being assaulted on B Wing and needed to get off the wing. It is generally
not advisable to hold people under ACCT supervision in the segregation unit
because it is a more stressful environment and offers less staff support. Mr Oleisky
asked to move to the segregation unit because he was fearful of reprisals on B
Wing. A nurse carried out the segregation health screen and the Head of Residence
completed the defensible decision log to support the decision to hold Mr Oleisky in
the segregation unit. We are satisfied that it was reasonable to conclude Mr Oleisky
could be safely located in the segregation unit.
93. On 7 September, he was moved back to B Wing after he said he could not cope on
the segregation unit. Very soon after, he tied a dressing gown cord around his neck
and then cut himself. He was then moved to G Wing, where he tied a shoelace
around his neck, which resulted in his death.
94. We accept that prison staff were in a difficult position with regard to where to place
Mr Oleisky. On 7 September, he told them that he could not cope on the
segregation unit, and he was tearful and upset. We consider that it was appropriate
to consider moving him from the segregation unit. According to the manager of the
segregation unit, the only option available was Mr Oleisky’s original cell on B Wing
and Mr Oleisky said he would rather move there than stay on the segregation unit.
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A CM said she was strongly opposed to a move back to B Wing, given that this
location was the original trigger for his self-harm.
95. We are concerned that the manager of the segregation unit appeared to take a
unilateral decision to move Mr Oleisky to B Wing. We consider that there should
have been a multidisciplinary discussion to decide on the best location for Mr
Oleisky. While this may have taken longer, it is likely to have resulted in a more
informed decision and staff could have placed Mr Oleisky on a higher level of
observations to keep him safe in the meantime. Given the background, we consider
that the move to B Wing was inappropriate, and alternatives should have been
considered.
96. It is also the case that Mr Oleisky later told staff he had contrived to get back to B
Wing so that he could self-harm again (possibly because he would have access to
more things and the staffing ratios are lower).
97. We recommend:
The Governor should ensure that where a prison on ACCT is moved from
segregation and there is a concern regarding potential risk created by a
return to normal location, then wider consultation should be sought prior to
the move taking place and an ACCT review arranged as soon as possible.
Delay in calling medical emergency code
98. PSI 03/2013, Medical Emergency Response Codes, requires all prisons to have a
medical emergency response code protocol in place, the purpose of which is to
ensure a timely, appropriate and effective response to medical emergencies. When
a medical emergency is discovered, staff should call the appropriate medical
emergency code straightaway so that relevant staff, including healthcare staff, are
alerted, the correct equipment is brought, and an ambulance is called immediately.
99. There was a delay in calling the medical emergency code when staff discovered Mr
Oleisky unresponsive. The officer entered the cell and cut Mr Oleisky’s ligature
before calling the code. While we understand that the officer focused on removing
the ligature and there was only a short delay in calling the code, it should
nevertheless have been done straightaway. We make the following
recommendation:
The Governor should ensure that staff are aware of their responsibilities
during medical emergencies and that staff who discover the emergency
should call the appropriate medical emergency code immediately.
Clinical care
100. The clinical reviewer found that the physical and mental health care Mr Oleisky
received was of a reasonable standard overall, and with the exception of some
instances of poor information sharing and record keeping, was equivalent to that he
could have expected to receive in the community.
101. The clinical reviewer noted that a nurse did not share information about the hooch
incident on 2 September with the DARS team.
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102. On 6 September, two nurses both saw Mr Oleisky at different times. His behaviour
was unusual, and the clinical reviewer considered that the reasons for it, in
particular the potential for it to be due to intense fear or his reaction to hooch, could
have been explored further and passed on to other staff. We make the following
recommendations:
The Head of Healthcare should ensure healthcare staff keep accurate and
timely records of significant contacts.
The Head of Healthcare should ensure that significant information is shared
promptly between healthcare services and where appropriate with wider
prison staff.
Inquest
103. The inquest, held on 20 March 2025, reached the following narrative conclusion:
“Tom deliberately did the act that ended his own life but his probable intent cannot
be ascertained. The causative issue was the decision at the ACCT Review on the
7th September 2022 not to remove items which could be used as a ligature.”
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