Who really cared for Piotr M when he died in Wandsworth prison in June 2021?
If you had a brother or son who was held in the prison and you knew he was depressed, what would you expect the prison to do? What help would you hope they could offer? Healthcare in the prison is supposed to be of the same standard as a person would receive in the community. That is the fallback position.
Representatives from WPIC held back tears through Piotr’s two-week inquest as they realised how poor that care could be. We listened in court with his family beside us as evidence was given which showed how his despair deepened and his attempts on his life increased in frequency and seriousness.
By the time he died Piotr had been put on the list for prisoners at risk nine times . He had gone from self harming with a blade to attempting to hang himself with torn up sheets . He was banging his head on the walls, bleeding, crying, smashing up his cell, and only talking to nurses with a blanket over his head.
But we learnt much more from the shocking evidence that came out during the hearing:
-that the prison system for those ‘at risk’ hinged on multidisciplinary team reviews. This was a sham at times with no one other than officers attending, or sometimes healthcare staff who had no knowledge of Piotr.
-that officers forged names on the review documents and possibly failed to do cell checks, certainly failed to check at the intervals they were supposed to use.
-some important evidence given by staff about the care Piotr was given was entirely contradictory. It was described by the official responsible as a misunderstanding, it smelt like a cover up.
-that superior officers themselves said that no meaningful interactions were being had with Piotr and that the paper file kept on the wing was inadequate.
-that the records kept by the officers and the records kept by the health team simply didn’t speak to one another and were not good enough.
-that there was no purposeful activity offered to a seriously depressed man left alone 23 hours a day, sometimes longer.
-that although Piotr had asked to share a cell, and had a willing friend, no real consideration was given to the issue.
-that on the night Piotr died, only one support officer was on duty on his wing of over 200 prisoners. That support worker had had only two weeks training ever and no first aid training, he was on his first overnight shift. Not surprisingly, he was too frightened to enter the cell and gave the wrong emergency call code. The ambulance was delayed by 20 minutes because of failures at the gate .
What can we say ? Sadly, none of this probably amounts to neglect in the eyes of the law but what do you think? Will anything improve? The prison told the coroner that their system for care for the vulnerable had changed and was improved. But Piotr died in 2021 and there have been six suicides so far in 2024.
Reports from families do not bear witness to any improvement .
Lessons should be learnt from the death of Piotr M, but will they be? This is our first inquest , but from now on we will follow them all.
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