Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0355, written 8 Nov 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 Nov 2022 |
|---|---|
| Reference | 2022-0355 |
| Deceased | Liridon Saliuka |
| Coroner | Philip Barlow |
| Coroner area | London Inner (South) |
| Category | State Custody related deaths · Suicide (from 2015) |
| Organisation named | Oxleas NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Governor, HMP Belmarsh 2. The Chief Executive, Oxleas NHS Trust 1 CORONER I am Philip Barlow, assistant coroner for the coroner area of Inner South London 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 14 January 2020 I commenced an investigation into the death of Liridon Saliuka, age 29. The investigation concluded at the end of the inquest on 3 November 2022. The conclusion of the inquest was suicide. The medical cause of death was partial suspension. 4 CIRCUMSTANCES OF THE DEATH Mr Saliuka had been a prisoner on remand at HMP Belmarsh since July 2019. He had sustained significant injuries in a car accident in 2018. He had been placed in a medical cell with a hospital bed and mattress. On 31 December he was moved to an ordinary single cell without a special bed or mattress. Mr Saliuka objected to the move because he believed he needed a special mattress to alleviate the pain from his injuries. On 2 January 2020 he hung himself in his cell. The cell move went ahead despite a governor’s recommendation that it be postponed pending clarification of the medical assessment. There was confusion and misunderstanding between prison staff, healthcare staff and social services as to: • the extent of Mr Saliuka’s disability • who was responsible for assessing it • what adjustments were required • who had recommended adjustments This also created confusion for Mr Saliuka who believed that he had been assessed for a special mattress and that this entitlement was being taken away by way of punishment. The jury’s conclusions were as follows: • There were repeated failings to consistently recognise the fact and extent of Mr Saliuka's disability resulting in further failure to implement reasonable adjustments, specifically relating to the provisions of an adequate mattress and to conduct an adequate medical assessment, prior to completing the move from the medical cell. • There were significant failures in the co-ordination of Mr Saliuka’s care, with inadequate record keeping. 1 • There were numerous instances of ill treatment of a discriminatory and dismissive nature, along with an insufficient willingness to address Mr Saliuka’s concern. • We consider the above to have negatively impacted on Mr Saliuka's mental health and thus constitute contributing factors to Mr Saliuka's suicide. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. To the Governor of Belmarsh and to the Chief Executive of Oxleas. There was no clear documentation (accessible by prison staff, healthcare and social services) of the adjustments that were required for the prisoner’s disability, 2. To the Governor of Belmarsh. There was a lack of disability awareness amongst prison staff of all levels. For example, there was an assumption that a prisoner could not be disabled because he used the gym and had good upper body strength. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 December 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: • Mr Saliuka’s family • Royal Borough of Greenwich • Change Grow Live I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. 9 8 November 2022 Philip Barlow 2
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Director General of Operations
HM Prison and Probation Service
8th Floor Ministry of Justice
102 Petty France
London
SW1H 9AJ
Philip Barlow
Assistant Coroner for Inner South London
HM Coroner’s Office
1 Tennis Street
London
SE1 1YD
12 January 2023
Dear Mr Barlow,
Thank you for your Regulation 28 report of 8 November 2022, addressed to the Governor of
HMP Belmarsh and the Chief Executive of Oxleas NHS Trust. I am responding on behalf of
His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.
I know that you will share a copy of this response with Mr Saliuka’s family, and I would first
like to express my condolences for their loss. Every death in custody is a tragedy and the
safety of those in our care is my absolute priority.
Following evidence heard at the inquest, you have raised concerns that there was no
clear documentation detailing the adjustments needed for Mr Saliuka’s disability and that
there was a lack of disability awareness amongst staff.
I am aware that Oxleas NHS Trust is providing a separate response, however I wish to
assure you that HMPPS is committed to the providing the necessary care for those in
custody with disabilities. Prison Service Instruction (PSI) 32/2011 is the national policy for
ensuring equality and it mandates that Governors must ensure that efforts are made to
identify whether a prisoner has a mental or physical impairment of any form and that
procedures are in place to record this information, while maintaining confidentiality.
On arrival at HMP Belmarsh all prisoners are assessed by a member of healthcare staff in
the First Night Centre, and prisoners are encouraged to disclose any disabilities they may
have. It is recognised that not all prisoners will be aware of or wish to disclose this
information, so staff will make every effort to identify whether a prisoner has a mental or
physical impairment of any form. If any disabilities are evident or disclosed, healthcare staff
must make the appropriate referrals and record this information on a prisoner’s record.
Healthcare staff must also advise operational staff working on the First Night Centre of any
immediate action that is required, such as making reasonable adjustments for the prisoner.
You will be aware that all reasonable adjustment assessments for HMP Belmarsh prisoners
are completed by the Royal Borough of Greenwich Social Care Team (RGB). The
timeframe for assessments may vary but RGB aim to asses prisoners within 2-7 working
days. Once the adjustments have been confirmed, a care plan and all other requirements
will be put in place and the prisoner will receive a letter detailing the adjustments.
Healthcare staff will document and upload the care plan and any other relevant documents
onto a prisoner’s healthcare record on SystmOne, with an entry detailing the required
adjustments also being made on the NOMIS case management system, so that this can be
accessed by operational staff.
In respect of your second concern, throughout 2023 HMP Belmarsh will be holding monthly
training sessions alongside Oxleas NHS Trust and RGB for all operational staff. These
sessions will focus on encouraging staff to think differently about disability, including those
that may not be visible, and to take action to improve how they engage with disabled
prisoners to ensure their needs are met, and the necessary support is offered. We will also
remind staff on how to access the documentation detailing any adjustments, and the
importance of doing so.
Thank you again for bringing your concerns to my attention. I trust that this response
provides assurance that action is being taken to address this matter.
Director General of Operations
19 December 2022
Private & Confidential
Mr Philip Barlow
Assistant Coroner
Southwark Coroner’s Court
1 Tennis Street
Southwark
SE1 1YD
Dear Mr Barlow
Pinewood House
Pinewood Place
Dartford
Kent
DA2 7WG
Tel:
Fax:
Website: www.oxleas.nhs.uk
Re: Response to Prevent Future Deaths Report touching the death of Mr Liridon Saliuka
(Date of Death 02.01.2020)
This response is made on behalf of Oxleas NHS Foundation Trust in response to the Regulation
28 Report to Prevent Future Deaths dated 8th November 2022 following the inquest touching
the death in custody of Mr Liridon Saliuka who died in custody in HMP Belmarsh on 02 January
2020, with the matter of concern outlined below;
To the Governor of Belmarsh and to the Chief Executive of Oxleas. There was no clear
documentation (accessible by prison staff, healthcare, and social services) of the adjustments
that were required for the prisoner’s disability.
I am writing to inform you that following this inquest the following improvements have now
been made.
When a patient is identified as requiring adjustments to their disability that these will now be
documented on the Prison Nomis (P-Nomis) system. Agreement was reached following senior
management review by HMP Belmarsh, Royal Borough of Greenwich Social Care and Oxleas
NHS Foundation Trust. All these providers have access to p-nomis.
All prison staff have been notified of this development and healthcare administrative staff
will be responsible for entering this information on P-Nomis. A fortnightly meeting involving
all providers has now convened allowing discussion of patients presenting with disability that
may be of concern, to facilitate improved care planning and communication.
We will audit progress made quarterly with effect from February 2023 and monitor this
through our local Quality board arrangements.
I hope my response has adequately addressed your concerns.
Yours Sincerely
Chief Executive
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