Source · Prevention of Future Deaths

Marcin Stoga

Ref: 2014-0576 Date: 21 Jul 2014 Coroner: Darren Salter Area: Oxfordshire Responses identified: 1 / 1 View PDF

Crucial information regarding a prisoner's overdose history was not available during initial assessment. Furthermore, prisoners with mental health risks are not routinely or thoroughly assessed upon return from court, leaving significant gaps in their care and safety.

Date 21 Jul 2014

56-day deadline 15 Sep 2014 est.

Responses identified 1 of 1

State Custody related deaths

Coroner's concerns

AI summary

View full coroner's concerns

In the circumstances it is my statutory duty to make this report to you: (1) Prior to Mr Stoga's arrival at HMP Bullingdon, there was a Prisoner Escort Record which referred t0 the fact that Mr Stoga had taken an overdose in 2012. It appears_that Stoga The day the wili this form and this information was not available to the Prison Officers or the Healthcare Nurse who initially assessed Mr Stoga upon his arrival. One would have thought that the form or at least the information on the form should routinely be available to those responsible for carrying out initial assessments of this nature (2) A secand concern, which is t0 some degree related ta the first, is the fact that prisoners (particularly those with mental health difficulties or who are otherwise at mediumlhigh risk of self-harm) are not routinely assessed on return court hearings. Mr Stoga attended court on December 2012 and again on 11 February 2013 and 23 April 2013, the day before his death: There were no such assessments. On this last occasion it is believed that Mr Stoga was charged with assaulting his partner: L understand from evidence and information at Inquest that there has been & review (and that this issue also formed part of the PPO Recommendations) and that persons returning from court will be seen by the Duty Reception Nurse to ascertain any change in circumstances What is not clear is if this is anything other than a cursory assessment: It appears that a more thorough assessment is likely to be required for those prisoners who have a history of mental health issues and are believed to be at a mediumlhigh risk of self-harm or suicide. It appears there may be a need for some written guidance for staff or perhaps a protocol: appreciate that the two concerns have outlined are partly within the responsibility of prison staff and partly that of Healthcare staff Consequently, anticipate it will be necessary for you to liaise with the Head of Healthcare It seems to me however that overall responsibility for the safety of prisoners rests with the Governor and HM Prison Service_

Responses

1 respondent

HM Prison and Probation Service Central Government

29 Dec 2014 PDF

Action Planned

HM Prison and Probation Service is trialling revised Prisoner Escort Records including a 'Red Flag' page to highlight key risk/vulnerability information. They also highlight existing protocols for screening prisoners returning from court for healthcare or self-harm issues. (AI summary)

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Dear the my key from being key key

risklvulnerability information. This will provide all persons coming in to contact with the prisoner to record any concerns regarding the prisoner's welfare Your second concern related t0 evidence that Mr Stoga had not been assessed for risk of self harm on return from his court appearances. PSO 3050 "Continuity of Healthcare for Prisoners states that
6.2 Events that require a prisoner to leave the prison and pass back through prison reception can have a significant impact on the health of a prisoner. Exampies of such events are as follows: Court appearance Sentencing at court Retur from home visit
6.3 For those prisoners passing through reception, prisons must have protocols in place for screening (hem for any potential healthcare, or suicidelself-harm issues Evidence at the inquest confirmed that prisoners returning from court are seen by the Duty Reception Nurse to ascertain any change in circumstances, and assess whether there has been any impact on their risk of self-harmlsuicide or to their mental health. In addition, staff can refer prisoners to healthcare at any time where have concerns about a prisoner's mental health Any retuming prisoner subject to an ACCT, can be referred for a mental health assessment at any stage within the process that you find this information helpful:.

Report sections

Investigation and inquest

In April 2013 commenced an Investigation and then opened an Inquest on 2 May 2013 into the death of Marcin Jacek STOGA, aged 27 who died on 24 April 2013 at HMP Bullingdon. concluded the case at Inquest on 30 June 2014 at Oxford Coroner's Court As it was 3 death in custody, it was a jury Inquest: A copy of the Record of Inquest completed by the jury is attached It will be seen that the jury gave a narrative verdict which confirmed that Mr Stoga committed suicide but went on to say that in the jury's view there were missed opportunities to support the prisoner which were of a systemic nature: Members of_staiff_from_the_nrison and Healthcare gave oral evidence as did Deputy Governor anticipate that you will have received a report about the Inquest:

Circumstances of the death

circumstances are Of course known to you but, briefly, Marcin had been at Bullingdon Prison since November 2012 on remand . The main charge against him was the attempted rape of a prostitute and, if convicted, he could expect a lengthy prison sentence_ It was his first time in a UK prison He spoke little English He had been to court on 23 April which is the before his death It is believed he was due to return to court at the end of April He was found hanging in his cell on the afternoon of 24 April. have not provided you with a copy of the Inquest file because the file was disclosed to prison/ Treasury Solicitors prior to Inquest

Action should be taken

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

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Shared signals

Report details

Reference: 2014-0576
Date of report: 21 July 2014
Coroner: Darren Salter
Coroner area: Oxfordshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 15 Sep 2014 (estimated).

Sent to

HMP Bullingdon

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.