Source · Prevention of Future Deaths

Liridon Saliuka

Ref: 2022-0355 Date: 8 Nov 2022 Coroner: Philip Barlow Area: Inner South London Responses identified: 2 / 2 View PDF

There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.

Date 8 Nov 2022

56-day deadline 28 Dec 2022

Responses identified 2 of 2

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

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.

Responses

2 respondents

Oxleas NHS Foundation Trust NHS / Health Body

19 Dec 2022 PDF

Action Taken

Oxleas NHS Foundation Trust will now document adjustments required for a patient's disability on the Prison Nomis (P-Nomis) system, accessible by prison staff, healthcare, and social services. 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. (AI summary)

View full response

Dear Mr Barlow

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.

Pinewood House Pinewood Place Dartford Kent DA2 7WG

Tel: Fax: Website: www.oxleas.nhs.uk

I hope my response has adequately addressed your concerns.

HM Prison and Probation Services Central Government

12 Jan 2023 PDF

Action Planned

HMP Belmarsh will be holding monthly training sessions throughout 2023, alongside Oxleas NHS Trust and RGB, for all operational staff. These sessions will focus on encouraging staff to think differently about disability and to improve how they engage with disabled prisoners. (AI summary)

View full response

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

Report sections

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.

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.
• 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.

Copies sent to

Royal Borough of GreenwichChange Grow Live

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Report details

Reference: 2022-0355
Date of report: 8 November 2022
Coroner: Philip Barlow
Coroner area: Inner South London

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 28 Dec 2022.

Sent to

HMP Belmarsh

Oxleas NHS Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.