Lewis Petryszyn

GRAEME HUGHES CORONER'S OFFICE
HIS MAJESTY’S THE OLD COURTHOUSE
SENIOR CORONER COURTHOUSE STREET

PONTYPRIDD
SOUTH WALES CENTRAL
CORONER AREA CF37 1JW

Telephone:
Email:
ANNEX A

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1}

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT TO:

The Chief Executive Cwm Taf Morgannwg University Health Board
G4S Care & Justice Services UK Ltd

CORONER

| am Patricia Morgan Area Coroner, for the coroner area of South Wales Central.
CORONER’S LEGAL POWERS

2 || 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.

INVESTIGATION and INQUEST

On 25 April 2022 | commenced an investigation into the death of Lewis Rhys
Thomas PETRYSZYN . The investigation concluded at the end of the inquest 09/04/2025.

The jury conclusion of the inquest was that Lewis Petryszyn's death occurred as a
‘consequence of inhalation of drugs. He inhaled them without intending to end his life.

1a Unexpected death from inhalation of synthetic cannabinoids
ib
1c

ll
(CIRCUMSTANCES OF THE DEATH

|
[These are recorded as:-

|On Friday 15th April 2022 between 13:45pm and 14:27pm, Mr Petryszyn died in his shared cell on
(Alpha 4 Block, HMP Parc, 1 Heol Hopcyn John, Coity, Bridgend, by inhalation of synthetic
jcannabinoids.

[The Inquest focused upon:-

i. Mr Petryszyn’s use of Psychoactive Substances at HMP Parc since 6 May 2021
ii. The steps taken by HMP Pare to safeguard Mr Petryszyn from drug use while in|
|

custody until his death on 15 April 2022
ii, | The circumstances in which Mr Petryszyn came to ingest psychoactive substances,
on 15 April 2022

iv. The emergency response to Mr Petryszyn being found unresponsive in his cell on
15 April 2022, and whether there were any missed opportunities to render care.

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 will 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) There was, and remains, an absence of specified prescribed timeframes in policies
and procedures within which intervention, ongoing support, and/or case load allocation
to/from Dyfodol must occur for prisoners likely to be at risk of substance misuse.

(2) The absence of prescribed timeframes poses the real risk of delayed support and
intervention to drug users

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and | believe you and your
organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by 25th September 2025.

|, 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.

COPIES and PUBLICATION

| have sent a copy of my report to family who may find it useful or of interest.

| am also under a duty to send the Chief Coroner a copy of your response.

|The Chief Coroner may publish either or both in a complete or redacted or summary form.
|She may send a copy of this report to any person who she 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 by the Chief Coroner.

31 July 2025

\SIGNED: f

Patricia Morgan Area Coroner for South Wales Central Coroner Area

HM Area Coroner Mrs P Morgan
South Wales Central Coroner’s Court
The Old Courthouse
Courthouse Street
Pontypridd
CF37 1JW

By email only:

CLYDE&CO

Clyde & Co LLP
2 New Bailey Square
Stanley Street
Salford
M3 5GS
Telephone: 0161 236 2002
Fax: +44(0)161 832 7956
DX 14302 Manchester
www.clydeco.com

Our Ref:

Your Ref:

Date:
19 September 2025

Dear Madam

Inquest touching the death of Lewis Petryszyn

We write in response to your Regulation 28 report to prevent future deaths dated 31 July 2025  addressed to
The Chief Executive Cwm Taf Morgannwg University Health Board and G4S Care & Justice Services UK Ltd.

Ongoing Concerns Identified

1.  There  was,  and  remains,  an  absence  of  specified  prescribed  timeframes  in  policies  and
procedures  within  which  intervention,  ongoing  support,  and/or  case  load  allocation  to/from
Dyfodol must occur for prisoners likely to be at risk of substance misuse.

2.  The absence of prescribed timeframes poses the real risk of delayed support and intervention to

drug users.

Response

On 15 December 2022, the contract for the provision of healthcare services at HMP &  YOI Parc  (HMP Parc)
transferred  to  the  new provider  Cwm  Taf  Morgannwg  University  Health  Board  (CTMUHB).  Pursuant  to  this
contract  responsibility  for  the  provision  of  clinical  and  non-clinical  substance  misuse  services  at  HMP  Parc
transferred to CTMUHB, the new provider.

CTMUHB  commissioned  Dyfodol,  part  of  G4S  Community,  to  provide  non-clinical,  psychosocial  substance
misuse  services  at  HMP  Parc  from  approximately  September  2023.  Responsibility  for  provision  of  clinical
substance misuse services at HMP Parc remains with CTMUHB.

The specification requirements for psychosocial substance misuse services at HMP Parc include the following
relevant provisions:

1.  The overriding principle of  the contract  is that all residents of HMP Parc will have access to the same
range and quality of services as the general public receives from the National Health Service (NHS).

2.  Service Description:

a.  Acceptance of all referrals made to the provider by the early days in custody team.
b.  Develop and support the delivery of the Drug Education Programme that provides education and

awareness of drug misuse in prison to staff, prisoners and children.

c.  Where it is deemed ongoing support is required by prisoners and children, they will be accepted

onto the service caseload.

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d.  Those prisoners and children who are accepted on the caseload will be allocated a case worker
who is responsible for assessment, care planning, coordinating the care plan, 1 to 1 support and
providing appropriate reports for the prisoner or child eg parole reports.

e.  Provide  a  brief  intervention  service  that  includes  short-term,  targeted,  structured  support  for

prisoners and children with an identified treatment need for substance misuse.

f.  Operate an  open  access  service that  allows all  prisoners and  children in HMP  Parc  to access

support as and when required upon request or in response to a specific incident.

g.  Operate  a  "Duty  Line"  Monday  to  Friday  within  specified  hours  which  allows  prisoners  and

children to speak directly to a member of the team or via the CMS messaging system.

h.  Deliver a minimum of 20 hours per week group work through the psychosocial substance misuse

team and external partners.
Include the provision of a specialist counselling service for 3 days per week.

I. 
J.  Provide an open access responsive service that includes Psychoactive Substances (PS) Rapid
Response which supports all adults and children who have been involved in an incident relating
to  psychoactive  substances and  provide harm  reduction  advice and  brief  intervention support
with the aim of keeping people safe.

k.  Provide information to support the ongoing care or treatment of a resident post release.
l.  For  those  prisoners  and  children  who  test  positive  as  part  of  Mandatory  Drug  Testing  (MDT)
provide  information  and  advice in  relation to  the  substance they  have  tested  positive  for  and
details of how to contact the service.

m.  For frequent MDT failures provide brief intervention.
n.  Employ  and  line  manage  prisoner  recovery  peer  mentors  who  provide  support,  advice  and

information to prisoners and children in recovery.

o.  Participate  in  release  planning  for  prisoners  and  children  to  ensure  a  collaborative  approach

where all needs are met.

3.  Performance:

a.  The Provider must ensure that all prisoners identified as having substance misuse have an initial
care plan completed within 3 days (this considers the initial assessment and  contact completed
during the early days in custody period).

b.  The Provider must ensure that all prison releases with ongoing substance misuse needs that are
clinically managed have transfer of care arrangements in place with community services prior to
release to ensure continuity of care.

c.  The Provider must deliver a minimum of 20 hours of intervention work a  week (including group

work and counselling).

d.  The Provider must deliver a weekly consultation clinic jointly with healthcare providers.
e.  The Provider must ensure that all prisoners identified as suitable for brief intervention treatment

will receive support within 4 weeks of referral date.

As outlined in the previously provided statements of Mike Vigar, Functional Head of Rehabilitation at HMP Parc,
dated 10 March 2025 and 15 April 2025:

(cid:127) 

(cid:127)  At the heart of the HMP Parc Drug Strategy is the prison’s dedicated recovery service. The psychosocial
service is contracted by the Health Board (CTMUHB) and delivered by G4S Community, rather than by
HMP Parc.
The  Dyfodol service moved  to  a  3  tier  case  management model,  with  individuals either  on  caseload,
receiving  targeted  brief  intervention  sessions  or  accessing  the  open  access  service  where  required,
allowing resources to be  focused on those most in need  whilst also being able  to respond and support
those  in  crisis  and  delivering  effective  intervention  and  support  to  those  with  a  short  term  identified
treatment need.

(cid:127)  Recovery  peer  mentors  are  a  crucial  part  of  the  HMP  Parc  Drug  Strategy  who  provide  training  and

(cid:127) 

(cid:127) 

oversight to staff  and prisoners.
The PS Rapid Response Service ensures all prisoners identified as  using psychoactive substances in
custody are seen within 24 working hours by a member of the Dyfodol service with the offer of education,
advice, guidance, support and onward referrals.
The SMOR (Substance Misuse Observation Record) is the key process of safeguarding those identified
as being under the influence of substances.

10369130 (Inquest touching the death of Lewis Petryszyn (G4S Care & Justice Services (UK) Limited))

Clyde &. Co LLP is a limited liability partnership registered in England and Wakti under number  OC326539 and  s  authoreted arid  req da ted by  the Solicitors Regulafkxi AuEliorily under
number 460690.  A i s1 of members  available for Inspection a1 its registered offtoe The St BoWph Building, 133 Houndsdrtcti, London EC3A  TAR.  Clyde 4  Co LLP uses Die ivond
"partner* to refer Io a mcmticr of thio LLP, or an employee ar  consultant witbi equivalent standing and quaiificabans.

 (cid:127) 

The Drug Education Programme provides a non-judgmental overview of the presence of substances in
custody,  the  potential risks,  choices and  support  available.  It  is  presented to  all  prisoners arriving at
HMP Parc  as part of  the  induction process.  It is presented collaboratively by  members of  the Dyfodol
service and peer mentors with lived experience of the issues being considered.

CLYDE & C O

(cid:127) 

(cid:127)  All  prisoners  receive  a  mandatory  initial  substance  misuse  induction  assessment  within  the  first  24
working hours of arrival at HMP Parc.  Recovery peer mentors also visit prisoners during the early days
period  to signpost prisoners to Dyfodol  services, to  support referrals and  to  provide information about
the prison’s two Recovery Pathways Units.
There is a twice weekly Clinical Substance Misuse Assessment Clinic attended by clinicians and Dyfodol
caseworkers.
There  are  two  dedicated  Recovery  Pathways  Units  at  HMP  Parc.  Assessments, interventions,  peer
group work  and activities all take place on the units and more  widely around the prison.  Prisoners are
able  to  engage  in  structured  recovery  focused  interventions,  peer-led  groups  and  holistic  activities,
alongside clinical interventions.

(cid:127) 

(cid:127)  Prisoners  receiving  ORT  (opiate  replacement  therapy)  are  automatically  taken  onto  the  Dyfodol

caseload.

(cid:127)  Every prisoner and member of staff at the prison is encouraged to undertake naloxone training.
(cid:127) 

The Dyfodol team is  made  up  of  dedicated caseworkers, early  intervention  practitioners and  assistant
psychologists.  Dedicated counselling is provided by New Pathways.

(cid:127)  A case conference model has been developed to ensure a multidisciplinary approach to support people

(cid:127) 

(cid:127) 

using substances.
There  are  no  nationally prescribed  timescales set  out  for  delivery of  substance misuse  services other
than those relating to initial assessment, care plan creation and release planning.
The Dyfodol team carries out the initial induction assessment for all newly arriving prisoners on the next
working day after  their arrival at the prison.

(cid:127)  During the induction assessment interview, the Dyfodol early interventions practitioner decides what tier

of service is best suited for each individual.

(cid:127)  A prisoner who is assessed as requiring caseload allocation is referred on the day of the initial induction
assessment to the Dyfodol administrator for caseload allocation.  The prisoner is allocated to a Dyfodol
caseworker  within  3  working  days  of  the  initial  induction  assessment  in  compliance  with  the  service
guidelines.

(cid:127)  A prisoner may be identified as requiring a brief intervention either during the initial induction assessment
or at any  other point during the prisoner's period in custody. The  referral to brief intervention is  triaged
using  a  RAG  (Red,  Amber,  Green)  scale  to  determine urgency  and  need.  The  prisoner  will  then  be
allocated to the  next available brief intervention -  which may  be a group session or 1 to 1 session or a
mixture of  group work and 1 to 1 sessions.  Initially, a  prisoner has  up to 10 brief intervention sessions
available to them.

(cid:127)  Dyfodol early interventions practitioners offer brief interventions on a daily basis as part of their  weekly

rota.

(cid:127)  Dyfodol are contracted to deliver either group brief interventions or individual brief interventions within 4
weeks of allocation for brief intervention.  This requirement is complied with and 4 weeks is the maximum
length  of  wait,  with  many  brief  interventions  provided  much  more  quickly.  This  timeframe  applies
regardless of whether the referral for brief intervention is made  at the initial induction assessment or at
any other time during the prisoner's period in custody at HMP Parc.

(cid:127)  Whilst a prisoner is on the  waiting list for a 1 to  1 brief intervention they have  immediate access to and
are able to attend group brief intervention sessions and ongoing rolling programmes running throughout
the week which are offered every  working day by the Dyfodol service and which are run by Dyfodol staff
and/or peer recovery mentors.
The Dyfodol duty  telephone line is available for prisoners to call every  working day  between 08:00 and
09:00  and  13:15  and  14:15.  Any  request  made  using  this  service is  dealt  with  on  the  same  day  it  is
received as  part  of  the responsibilities of  the Dyfodol worker allocated to  that  role that  day.  Prisoners
can access the duty helpline using their in-cell telephone.

(cid:127) 

(cid:127)  Dyfodol responds to all SMORs, positive MDTs/voluntary drug tests (VDTs)or drug finds within 24 hours.
All  SMORs when  opened/positive MDTs/VDTs and  drug finds  are  noted on the  Duty  Director's log for
the  day.  The  following  day,  the  Dyfodol  administrator  creates  a  list  of  all  relevant  prisoners
(SMOR/positive  MDT/VDT/drug  find)  using  the  information  from  the  Duty  Director’s  log.  That  list  is

10369130 (Inquest touching the death of Lewis Petryszyn (G4S Care & Justice Services (UK) Limited))

Clyde &. Co LLP is d limited liabil "y partnership registered in England and Waled under number  OC326539 and  s  auEhurtsed arid  req dated by Die Solicitors Regulation Authority under
number 460690.  A i si of members >s available for Inspecbon al Its registered offtoe The St BoWph Building, 133 Houndsdrtcti, London EC3A  TAR.  Clyde 4  Co LLP uses Die svord
"partner" to refer Io a mcrrticr of thic LLP, ar an employee ar  consultant witrt Equivalent standing and quatiftcabons.

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emailed to  all members of the Dyfodol team.  Every individual on the list is visited by  a member of the
Dyfodol team  as  part  of  the  PS  Rapid  Response Service.  This  visit  is  in itself a  brief  intervention.  A
prisoner  may  be  allocated  to  caseload,  or  referred  for  further  brief  intervention  or  allocated  to  open
access  service as  a  consequence of  the  PS  Rapid  Response visit.  If  an  individual is  allocated for  a
further brief  intervention, this  will  take  place  within a  maximum period of  4  weeks  as  per  the  contract
specification.

(cid:127)  Every  prisoner before they  are released from the prison has a pre-release appointment with a Dyfodol
case  worker.  This  appointment takes place  up to  4  weeks before the prisoner leaves and  is to  check
that  all  necessary referrals have  been  made  to  community services and  that  all  support required is in
place.

(cid:127)  All prisoners receive a naloxone kit with their property when they leave the prison.
(cid:127)  PS  Rapid  Response  Service  and  SMORs,  including related  interventions  and  engagements,  are  not

nationally required but enhanced support initiatives run by Dyfodol at the prison.

As  outlined  above,  the  responsibility  for  the  provision  of  substance  misuse  services  at  HMP  Parc  lies  with
CTMUHB.  CTMUHB  has  determined  the  specification requirements  for  the  psychosocial  substance misuse
services at HMP Parc.  The psychosocial element of substance misuse services is subcontracted by CTMUHB
to  Dyfodol  which  is  part  of  G4S  Community.  In  the  circumstances,  other  interested  persons  to  whom  the
Regulation 28  report has  been  addressed are  better able  to consider the  concerns raised, take action and/or
explain why no action is proposed.

It can  be  seen from  information already provided that  the contractual specification agreed for  the provision of
psychosocial services by Dyfodol at HMP  Parc includes timeframes regarding initial assessment, allocation to
caseload, creation of  care  plans  and  timeframes for  provision  of  brief  interventions. All  these  timeframes are
complied with as outlined in evidence previously submitted and as reiterated above.

Those prisoners who  are  at the  highest level of risk  regarding substance misuse  would usually  be taken onto
caseload for 1 to 1 support from a dedicated Dyfodol caseworker. Brief intervention should be targeted where
there  is  a  specific  identified treatment  need  that  can  be  addressed over  a  defined period  of  time.  Dyfodol is
contracted to provide therapeutic interventions, working with individuals to develop new lifestyles to allow them
to build for a better future.

Psychosocial  support  is  crucial  and  offers  the  opportunity  to  engage,  to  provide  advice,  support  and
encouragement,  however,  prisoners  ultimately  have  the  choice  whether  they  participate  and  opt  in  to  work
towards long-term change.

No  action  is  proposed  regarding  timeframes  for  intervention,  ongoing  support  and/or  caseload  allocation
because  there  are  already  timeframes  contained  within  policies  and  procedures  as  required  nationally  and
pursuant to the service level agreement with CTMUHB, and those timeframes are complied with.

Dyfodol is  present at  every  touch point  of  the  justice system across South Wales, including at police custody
suites, court custody suites and HMPPS and privately operated prisons.  Dyfodol Community sits within all those
services to offer continuity of care and consistency of support for individuals with substance use issues.

We  trust  this  information  is  of  assistance  and  provides  reassurance  to  the  extent  that  G4S  Care  &  Justice
Services is able to take action.

Yours faithfully

Clyde & Co Claims LLP

10369130 (Inquest touching the death of Lewis Petryszyn (G4S Care & Justice Services (UK) Limited))

Clyde & Co LLP is a limited liability partnership registered in England and Wales under number OC326539 and is authorised and regulated by the Solicitors Regulation Authority under
number 460690.  A list of members is available for inspection at its registered office The St Botolph Building. 138 Houndsditch, London EC3A 7AR.  Clyde & Co LLP uses the word
"partner" to refer to a member of the LLP. or an employee or consultant with equivalent standing and qualifications.