Aleksandras Maslennikovas

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Independent investigation
into the death of
Mr Aleksandras Maslennikovas,
a prisoner at HMP Wandsworth,
on 17 July 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Aleksandras Maslennikovas, a Lithuanian national who spoke little English, was found
hanged in his cell on 17 July 2023 at HMP Wandsworth. He was 47 years old. I offer my
condolences to Mr Maslennikovas’ family and friends.
Mr Maslennikovas was the fourteenth self-inflicted death at Wandsworth in three years. Up
to the end of November 2024, there had been five further self-inflicted deaths since Mr
Maslennikovas’ death. Six out of the nine most recent self-inflicted deaths were foreign
national prisoners.
Both HM Inspectorate of Prisons and the Independent Monitoring Board concluded that
the shortage of available staff seriously undermined the prison’s ability to function
effectively. Staff struggled to provide even a limited regime and incidents of self-harm, and
the number of prisoners being monitored by suicide and self-harm prevention procedures
(ACCT) had risen. In May 2024, HM Chief Inspector of Prisons issued an Urgent
Notification to the Secretary of State for Justice in relation to the very poor outcomes for
prisoners witnessed at the most recent inspection.
It is difficult to say how well Mr Maslennikovas’ risk of suicide and self-harm was assessed
because interpreting services were not used, and he did not speak English well. Five days
before his death, staff started ACCT procedures after he made cuts to his arm and said he
was under threat but closed them 16 hours later. Wandsworth has recognised this failure
in their management of Mr Maslennikovas and have begun work to rectify the problem.
The clinical reviewer concluded that interpreting and record keeping issues meant it was
not possible to determine whether the clinical care Mr Maslennikovas received at
Wandsworth was equivalent to what he could have expected to receive in the community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman February 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 13
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Summary
Events
1. On 14 June 2022, Mr Aleksandras Maslennikovas was remanded to HMP
Wandsworth. A European arrest warrant for armed robbery had been issued in Mr
Maslennikovas’ home country of Lithuania. Mr Maslennikovas spoke little English.
This was his first time in prison.
2. Mr Maslennikovas had a history of anxiety and depression. Despite Mr
Maslennikovas’ language barrier, staff never used the formal interpreting services
available at Wandsworth and they sometimes used other prisoners to interpret.
3. Mr Maslennikovas was drug dependant in the community. When he was unable to
obtain heroin, he abused alcohol. When he arrived at Wandsworth, he was referred
to the substance misuse team and started on opiate substitution therapy (OST,
where the prisoner is maintained on a dose of methadone), with the dose increased
as needed to manage his withdrawal symptoms. Mr Maslennikovas was also
prescribed an antidepressant for generalised anxiety.
4. In September, Mr Maslennikovas requested a reduction in methadone as he wanted
to be drug free. Substance misuse staff reduced his methadone weekly and in
October, Mr Maslennikovas started a ten-day detoxification programme of
buprenorphine. However, once he completed the programme, substance misuse
staff did not review Mr Maslennikovas and he did not have any further engagement
with substance misuse services.
5. Mr Maslennikovas had no contact with his family and did not receive any visits. His
last telephone contact with his friend was in February 2023.
6. There are no key worker entries, or any evidence of meaningful conversations with
wing staff, in Mr Maslennikovas’ prison record.
7. In December, prison staff found fermenting liquid in Mr Maslennikovas’ cell. There is
no evidence that this information was shared with healthcare staff.
8. On 12 July 2023, Mr Maslennikovas made four substantial cuts to his left arm and
staff started suicide and self-harm monitoring (known as ACCT). He said that he
was under threat from Lithuanian prisoners on the wing. The following morning,
during an ACCT review, Mr Maslennikovas said he was no longer under threat and
had no concerns. Wing staff closed the ACCT. No healthcare staff were present at
the review.
9. On 14 and 15 July, Mr Maslennikovas’ behaviour deteriorated, and he purposely
burnt pieces of paper and damaged the furniture in his cell. He was hostile towards
staff and said he was under threat and wanted to move wing. Staff did not consider
whether his risk of suicide or self-harm had increased but moved him to another
wing.
10. At around 8.34am on 17 July, a prisoner went to Mr Maslennikovas’ cell. The cell
door observation panel was covered so the prisoner looked through the crack in the
bottom of the cell door, saw Mr Maslennikovas with something around his neck and
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alerted an officer. The officer blew their whistle for staff assistance. Another two
officers responded, opened the cell, and radioed a medical emergency code.
Control room staff called an ambulance at 8.38am. Staff used their anti-ligature
knife to cut the ligature and started cardiopulmonary resuscitation (CPR).
Healthcare staff arrived at 8.39am and assisted with resuscitation attempts until
paramedics arrived at 8.49am. At 9.37am, a paramedic pronounced Mr
Maslennikovas’ life extinct.
Findings
11. Mr Maslennikovas had multiple risk factors for suicide and self-harm, including
being a foreign national prisoner, awaiting extradition, a history of mental ill-health
and self-harm, a history of substance misuse and no contact with his family.
Management of Mr Maslennikovas’ ACCT was poor. There was no multidisciplinary
input during the only case review and despite a serious act of self-harm, there was
no clear assessment of Mr Maslennikovas’ risk. The ACCT was closed 16 hours
after being opened and only four days before his death.
12. Staff did not make use of the formal interpreting services available and there were
incorrect notes in Mr Maslennikovas’ prison record indicating that he spoke English.
Staff used other prisoners to interpret for Mr Maslennikovas which, given that he
complained he was being threatened by other Lithuanian prisoners, did not serve
his needs well and breached Wandsworth’s foreign national strategy.
13. There are no key worker entries in Mr Maslennikovas’ prison record, nor any record
of any meaningful conversations between staff and Mr Maslennikovas. Staff missed
opportunities to monitor Mr Maslennikovas’ welfare and to support him with any
concerns he might have had.
14. Mr Maslennikovas was appropriately referred to substance misuse services and
engaged with treatment. But there were omissions in the review process once he
had completed his detoxification programme.
15. The clinical reviewer concluded that it was not possible to judge whether the clinical
care offered to Mr Maslennikovas at Wandsworth was equivalent to what he could
have expected in the community because formal interpreting services were not
used to assess his care needs. However, the clinical reviewer concluded Mr
Maslennikovas’ access to substance misuse services at Wandsworth was broadly
equivalent to what he could have expected in the community.
Recommendations
• The Head of Healthcare and the Substance Misuse Lead should ensure that there
is a system in place to provide follow up appointments to those undertaking an
opiate detoxification programme and includes a failsafe to ensure staff are alerted
to those who have not been reviewed at the end of the programme.
• The Governor and Head of Healthcare should identify the best way to share
intelligence and manage risk around alcohol misuse in those with substance misuse
problems.
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The Investigation Process
16. HMPPS notified us of Mr Maslennikovas’ death on 17 July 2023.
17. The investigator issued notices to staff and prisoners at HMP Wandsworth
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
18. The investigator obtained copies of relevant extracts from Mr Maslennikovas’ prison
and medical records and viewed CCTV footage. She also obtained the NHS
England 72-hour review and Oxleas Foundation Trust desktop review.
19. The investigator interviewed five members of staff at Wandsworth on 28 September
and 16 November 2023. The case was transferred to another investigator.
20. NHS England commissioned a clinical reviewer to review Mr Maslennikovas’ clinical
care at the prison. The investigator and clinical reviewer interviewed two healthcare
staff on 27 September 2023. The new investigator and clinical reviewer interviewed
two healthcare staff on 30 September and 1 October 2024.
21. We informed HM Coroner for London Inner West of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
22. The Ombudsman’s office wrote to Mr Maslennikovas’ next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Maslennikovas’ next of kin did not respond.
23. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Wandsworth
24. HMP Wandsworth is a local category B and C prison in London. It holds men in
eight residential wings. Oxleas NHS Foundation Trust provides physical and mental
healthcare services at the prison. There is an inpatient unit which accommodates
up to six prisoners with physical health needs and up to 12 prisoners with mental
health needs.
HM Inspectorate of Prisons
25. The most recent inspection of HMP Wandsworth was in April and May 2024. HMIP
issued an Urgent Notification on 8 May 2024 to which the Secretary of State had 28
days to respond. A debriefing paper had also been prepared and was publicly
available.
26. Inspectors noted that despite a high-profile escape in September 2023, significant
weaknesses remained in many aspects of security. They found that the rate of self-
harm was high and rising but around 40% of cell bells were not answered within five
minutes. Inspectors found that many prisoners were clearly in distress without an
appropriate level of support. There were weaknesses in the ACCT case
management process. Reviews did not always identify appropriate risks and care
maps were often blank or contained limited information. In their survey, only 37% of
prisoners who had been supported using ACCT said that they felt cared for. Many
prisoners inspectors spoke to said that ACCT reviews were perfunctory and rarely
helped them to deal with their problems. Rates of violence had increased, and in
February 2024, 44% of prisoners tested positive in random drug tests.
27. HMIP noted that Wandsworth was badly overcrowded, with a transient population,
over half of whom were remand prisoners. Living conditions were very poor, cells
were cramped and ill-equipped and the prison was too dirty. The buildings and
facilities needed investment to make them a decent standard. Only 41% of
prisoners said that staff treated them with respect. Inspectors found that very limited
time out of cell, absent staff and no key work reduced the opportunity for staff to
develop meaningful relationships with prisoners.
28. There was little purposeful activity, with most prisoners unemployed and spending
over 22 hours a day locked in the cells. Inspectors found that prisoners had no idea
when or if they would be unlocked each day or whether they would get access to
fresh air. There were consistent failures to enable access to healthcare services
due to prison staff absences.
29. Despite a full complement of officers, sickness, restricted duties and training
commitments meant that over a third could not be deployed to operational duties
each day. This led to curtailed regimes, cross-deployment and burnt-out staff. Staff
at all grades were inexperienced. HMIP noted that staff were not wilfully neglectful,
they just did not understand their role, and lacked direction, training and consistent
support from leaders.
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30. Inspectors concluded that the poor outcomes they found at Wandsworth stemmed
from poor leadership at every level of the prison, from HMPPS and the Ministry of
Justice, leading to systemic and cultural failings which had led to a shocking
decline.
Independent Monitoring Board
31. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to May 2023, the IMB highlighted
what it termed serious and fundamental concerns. These included staff shortages,
the prison not being safe and inhumane conditions.
32. The Board noted that Foreign Nationals (FNs) accounted for around 45% of the
prison population, they were drawn from over 80 different nationalities and their
interests were of major concern for the equalities team. (The largest numbers were
from Poland, Romania, Albania, Hungary and Lithuania.) The Board was pleased
that all wings had FN representatives to support prisoners directly, raising issues on
their behalf at the equalities monthly meetings. In reception, leaflets were available
in several languages, and this extended to the kiosks. The Big Word simultaneous
interpreting service was used occasionally. FNs were often given cells to share with
nationals from the same country. The representative of the BEST charity
(befriending and support team for foreign national prisoners), with very limited
resources, provided an excellent service but, overall, the level of support for FNs
remained patchy. Coping with the high number of nationalities, and a variety of
prisoners with different first languages and ethnicities, remained a constant
challenge.
Previous deaths at HMP Wandsworth
33. Mr Maslennikovas was the nineteenth prisoner to die at Wandsworth since July
2020. Of the previous deaths, 12 were self-inflicted, four were from natural causes,
one was drug related and the cause of one death had not yet been established. Up
to the end of November 2024, there have been five self-inflicted deaths since Mr
Maslennikovas’ death. As a result of these self-inflicted deaths and the Urgent
Notification issued by HMIP, Wandsworth is receiving additional support and
monitoring from HMPPS regional and national safety teams.
Assessment, Care in Custody and Teamwork
34. Assessment, Care in Custody and Teamwork (ACCT) is the Prison Service care-
planning system used to support prisoners at risk of suicide or self-harm. The
purpose of ACCT is to try to determine the level of risk, how to reduce the risk and
how best to monitor and supervise the prisoner.
35. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multi-disciplinary review meetings involving the prisoner. As part of the
process, a caremap identifying support actions is put in place. The ACCT plan
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should not be closed until all the support actions on the caremap have been
completed.
Key work
36. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners and helping people
settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework.
37. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
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Key Events
38. On 14 June 2022, Mr Aleksandras Maslennikovas was remanded to HMP
Wandsworth. A European arrest warrant for armed robbery had been issued for Mr
Maslennikovas in his home country, Lithuania. It was his first time in prison.
39. Mr Maslennikovas’ Person Escort Record (a document that accompanies prisoners
between police custody, court and prison) said that he had anxiety and depression
and that he only spoke Lithuanian.
40. An officer conducted Mr Maslennikovas’ first night interview. He noted that it was Mr
Maslennikovas’ first time in prison, and he said he did not have any self-harm or
suicide concerns. He noted that Mr Maslennikovas’ spoken language was
Lithuanian, that he spoke little English but spoke some Russian and Polish. Mr
Maslennikovas said that he had problems reading and writing in English. Despite Mr
Maslennikovas’ language barrier, there is no evidence that the officer offered or
used telephone interpreting services.
41. A nurse completed Mr Maslennikovas’ reception health screen. His urine sample
was positive for cocaine and opiates. Mr Maslennikovas said that he used heroin
and crack cocaine in the community. She referred Mr Maslennikovas to a GP and
the substance misuse service. In contrast to the officer’s assessment, she recorded
Mr Maslennikovas’ main spoken language as English and that an interpreter was
not needed.
42. A GP at the prison saw Mr Maslennikovas and started him on opiate substitution
therapy (OST, where the prisoner is maintained on a dose of methadone) and
prescribed 15 millilitres (ml) methadone. The GP used an online interpreting tool
(Google Translate) during the consultation.
43. Mr Maslennikovas was located on the first night induction unit.
44. Mr Maslennikovas did not have any contact with his family and did not receive any
visits during his time at Wandsworth. The only telephone number on his prison
phone account contact list was a friend. There is no record that he made a call to
anyone on his first day in prison; his last recorded contact with his friend was in
February 2023.
45. On 15 June 2022, Mr Maslennikovas attended a secondary health screen with a
nurse and a pharmacist at the prison. It was noted an interpreter was not thought to
be needed, although Mr Maslennikovas’ English was poor. Mr Maslennikovas said
that he was not registered with a GP and bought tramadol (an opiate pain relief)
from Lithuania for knee and elbow pain.
46. On 16 June, Mr Maslennikovas had his third day induction. He met with BEST
(befriending and support team for foreign national prisoners), Department for Work
and Pensions, Home Office immigration staff and probation staff. There is no record
that staff used interpreting services.
47. Mr Maslennikovas also met with a worker from Catch 22, a support service
specifically for foreign national prisoners (FNPs) which can help them apply for
asylum, among other services. She noted that Mr Maslennikovas did not speak any
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English. Mr Maslennikovas confirmed that he was due to be extradited to Lithuania
and had applied to the EU Settlement Scheme for settled status in the UK. Mr
Maslennikovas said that he did not have any thoughts of suicide or self-harm. He
said that he misused drugs and would like to be referred to Change, Grow, Live
(CGL), a charity that provides drug and alcohol addiction support and advice. Mr
Maslennikovas said that he was receiving methadone but was having trouble
sleeping. She noted she would refer him to the healthcare team.
48. On 19 June, Mr Maslennikovas asked for an increase in his methadone dose as he
was achy and having difficulty sleeping. The GP increased the methadone dose to
30ml.
49. On 20 June, a GP from the substance misuse services saw Mr Maslennikovas. Mr
Maslennikovas said that he was experiencing cramps, irritability, sweating and
generalised anxiety. He said that, in the community, when he did not have access
to heroin, he would use alcohol. The GP increased Mr Maslennikovas’ methadone
to 40ml and prescribed 15 milligrams (mg) of mirtazapine (antidepressant), to be
increased to 30mg after seven days.
50. That day, Mr Maslennikovas moved to a standard residential wing.
51. There are no keyworker entries, or any evidence of meaningful conversations with
wing staff, in Mr Maslennikovas’ prison record.
52. On 22 June, the GP from the substance misuse services increased Mr
Maslennikovas’ methadone to 45ml. On 15 July, Mr Maslennikovas attended his 28-
day review with a pharmacist at the prison. She noted that Mr Maslennikovas was
stable on 45ml of methadone.
53. On 28 July, a prison GP saw Mr Maslennikovas to discuss his trouble with sleeping.
Mr Maslennikovas had brought another prisoner to the consultation to interpret for
him. The GP prescribed 7.5mg of zopiclone (to aid sleep) for three nights and
advised Mr Maslennikovas to speak to the substance misuse services about
increasing his methadone.
54. On 1 August, Mr Maslennikovas requested to increase his methadone dose. The
GP from the substance misuse services increased the dose to 50ml.
55. Also on that day, a worker completed Mr Maslennikovas’ initial assessment for
education. He noted that Mr Maslennikovas should complete English for Speakers
of Other Languages (ESOL) classes, English and Maths level entry two.
56. On 2 August, Mr Maslennikovas moved to D wing, the drug recovery unit. He
shared a cell with a Latvian prisoner.
57. On 26 August, a worker from CGL saw Mr Maslennikovas. Mr Maslennikovas’
cellmate interpreted for him. Mr Maslennikovas thanked her but said that he did not
want any more assistance. She advised Mr Maslennikovas how to reconnect with
the team at any point.
58. On 5 September, Mr Maslennikovas requested a reduction in methadone. The GP
from the substance misuse services agreed, and Mr Maslennikovas’ methadone
was reduced by 5ml per week. The weekly reductions were actioned without any
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further discussions with Mr Maslennikovas, including whether he was coping with
the reduction in methadone.
59. On 6 October, a nurse saw Mr Maslennikovas. Mr Maslennikovas said that he
wanted to be drug free and the nurse started him on a 10-day detoxification
programme and prescribed buprenorphine, an opiate based medication which is
taken in tablet form under the tongue. At the end of the detoxification programme,
Mr Maslennikovas should have been reviewed, but this did not happen. Mr
Maslennikovas did not have any further engagement with the substance misuse
service. He continued to be prescribed 30mg of mirtazapine which he kept in his
cell and there is no evidence that healthcare staff reviewed him.
60. On 30 December, an illicit brewed alcohol detection (IBAD) dog found two litres of
fermenting liquid in Mr Maslennikovas’ cell. Staff placed Mr Maslennikovas on
report and gave him a suspended punishment (where the punishment, such as loss
of privileges or loss of earnings, is not initiated immediately, it lies on file and if the
prisoner is put on report again within the timeframe set, the punishment is initiated).
There is no evidence healthcare staff, or the substance misuse service, were
informed about the fermenting liquid find.
61. On 10 May 2023, an officer gave Mr Maslennikovas a behaviour warning after he
was seen passing items from his cell window to another prisoner in the exercise
yard.
62. On 27 June, Mr Maslennikovas attended court for an extradition hearing. The court
concluded that Mr Maslennikovas was to be extradited to Lithuania. It is not known
if Mr Maslennikovas was given a time frame for extradition.
63. On 3 July, Mr Maslennikovas sent an application to Catch 22 asking to speak to an
immigration worker. On 5 July, a worker from Catch 22 emailed Home Office
immigration staff and asked them to see Mr Maslennikovas. The immigration team
told us that they had no record of this email. There is no evidence that anyone from
the immigration team went to see Mr Maslennikovas.
Events of 12 – 16 July
64. On 12 July, Mr Maslennikovas made four substantial cuts to his left arm, which
required 10 stitches by healthcare staff (it is not documented what Mr
Maslennikovas used to cut himself). He said he had done this because he was
under threat from other Lithuanian prisoners on the wing. At around 6.00pm, an
officer started ACCT procedures. She set observations at one per hour. Staff noted
in the ACCT document that Mr Maslennikovas refused to engage in the care plan,
but they recorded that Mr Maslennikovas said he was under threat. Staff noted that
the protective factor (things that improved the situation) for this was ‘good support’,
but they did not record who would or could provide this support. Staff explained
what support was available to Mr Maslennikovas and ensured he had credit on his
phone to be able to contact friends and family. A Custodial Manager (CM) told Mr
Maslennikovas to self-isolate if a wing move could not be facilitated. There is no
evidence that interpreting services were used to communicate with Mr
Maslennikovas.
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65. At around 10.00am on 13 July, an officer completed the initial ACCT assessment
and then she and a Supervising Officer (SO) (since promoted to custodial manager)
held an ACCT review. There is no evidence that they used interpreting services. No
healthcare or mental health staff were present (and no evidence healthcare staff
were invited). There is no evidence that healthcare staff reviewed Mr
.
Maslennikovas aside from dressing his wounds. Mr Maslennikovas said that any
issues he had had with Lithuanians on the wing were resolved and he had no
further concerns. He said he had last self-harmed 17 years ago and did not know
why he had done it the previous day. He said he had support from family and his
children. (Mr Maslennikovas had no contact with family or friends and there is no
evidence that the SO or the officer took steps to confirm whether Mr Maslennikovas
had contact with his family.) Mr Maslennikovas said he had no other thoughts of
suicide or self-harm. The SO noted that Mr Maslennikovas was clean and well
kempt, engaged well and was open and honest. Due to Mr Maslennikovas’
presentation and claim that the issue of being under threat was resolved and he
would not self-harm again, the SO closed the ACCT.
66. Due to Mr Maslennikovas’ act of self-harm, his mirtazapine prescription was
changed to not in-possession meaning he would need to attend the medications
hatch on the wing each day to receive his medication. However, due to staff
shortages that day, prison staff were not able to escort Mr Maslennikovas to
medications hatch to receive his medication, so he had no medication that day. He
did not attend for his medication on 14 July either, but we do not know why.
67. At around 8.00pm on 14 July, Mr Maslennikovas deliberately burnt pieces of paper
in his cell and set off the fire alarm. He told an officer that he did it because he
wanted to move off the wing as he was under threat. The officer told Mr
Maslennikovas that she would mention his concerns to the night staff. There is no
evidence that staff investigated Mr Maslennikovas’ concerns or considered that he
was in the post-closure review phase of his ACCT and that this might indicate an
increase in his risk.
68. During the early hours of 15 July, Mr Maslennikovas damaged the furniture in his
cell and cut himself in the process. A nurse attended Mr Maslennikovas’ cell and
noted that he was hostile and would not allow him to assess the wound. Wing staff
did not think it was safe for the nurse to go into the cell. The nurse noted in Mr
Maslennikovas’ medical record that he ‘remains on ACCT’ rather than he was in the
post-closure review phase of the ACCT. The incident is not detailed in Mr
Maslennikovas’ prison record therefore it is not possible to say whether the duty
prison manager was aware, or whether wing staff made any consideration to Mr
Maslennikovas being in the post-closure review period.
69. At around 6.15pm that day, Mr Maslennikovas and his cellmate smashed a pipe in
their cell, causing flooding, and staff noted that they seemed to be encouraging
each other’s behaviour. Mr Maslennikovas’ behaviour was hostile, and he was
demanding a move to the care and separation unit (CSU, where prisoners can be
segregated away from other prisoners for their own safety, or for the safety of
others). Healthcare staff were unable to assess Mr Maslennikovas for injuries due
to his behaviour and made no follow-up appointment to assess him. There is no
evidence that wing staff explored the reasons why Mr Maslennikovas wanted to
move off the wing, or the change in his behaviour, and there is no evidence that
staff used interpreting services to help understand his concerns.
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70. Later that evening, Mr Maslennikovas was moved to a shared cell on B wing, a
standard residential wing. An officer held an interim ACCT review with Mr
Maslennikovas due to his move to B wing. There is no evidence that any other
prison staff or healthcare staff attended the review. Mr Maslennikovas told the
officer that he did not feel suicidal or have thoughts to self-harm but said he had
been very stressed on D wing. She noted that Mr Maslennikovas could not
understand a lot of English and decided that the ACCT post-closure review should
remain as 20 July, when the post-closure period was due to end. There is no
evidence that she used interpreting services during the review despite noting Mr
Maslennikovas’ difficulty with understanding English.
71. Between 10 and 18 July, the observation book for B wing showed it was a volatile
environment. Prisoners reported to staff that they did not feel safe and wanted to be
moved. Cell searches found improvised weapons, fermenting liquid, mobile phones
and illicit substances, and there were instances of violence between prisoners.
72. On 16 July, Mr Maslennikovas did not collect his mirtazapine prescription from the
medications hatch and there is no evidence that healthcare staff followed this up.
Events of 17 July
73. The following account has been taken using written evidence provided by
Wandsworth, CCTV footage and transcripts of interviews with staff and prisoners.
74. At 7.08am on 17 July, two officers, along with another prisoner, went to Mr
Maslennikovas’ cell to help his cellmate move his property as he had to attend
court.
75. At around 8.34am, a prisoner went to Mr Maslennikovas’ cell to speak to his
cellmate (who had left for court). The prisoner saw that the observation panel of the
cell door was covered with a towel. The prisoner knocked on the door, but there
was no response, so he bent down and looked under the cell door. He saw Mr
Maslennikovas with something tied around his neck. The prisoner banged on the
door again, but got no response so called over Officer A. The prisoner told the
officer that Mr Maslennikovas was hanging. She appeared to have a brief
discussion with the prisoner before she looked through the panel and then called to
an unknown staff member on the landing below for assistance, but they did not
respond so, at 8.37am, she radioed a code blue (indicating a prisoner is
unconscious or is having breathing difficulties). The control room called an
ambulance immediately.
76. Officer B responded and went to Mr Maslennikovas’ cell. Officer A opened the cell
door and went into the cell, while Officer B waited outside. Mr Maslennikovas had
used his dressing gown cord to hang himself from the top bunk bed. Officer C
arrived at the cell approximately 20 seconds later and called a code blue again.
Officer D had also arrived at the cell and immediately entered with Officer A and
Officer C. Officer C stepped back out of the cell as she could not hear staff coming
to assist and blew her whistle (she said the whistle was loud as she was concerned
staff might have turned their radio down). Officer C went back into the cell and
supported Mr Maslennikovas’ weight and Officer A used her anti-ligature knife to cut
the ligature. They placed Mr Maslennikovas on the floor and Officer D started CPR.
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77. Healthcare staff arrived at 8.39am and assisted with CPR and applied the
defibrillator, until paramedics arrived at the cell at 8.49am and took over CPR. At
9.37am, a paramedic pronounced Mr Maslennikovas’ life extinct.
Contact with Mr Maslennikovas’ family
78. The prison appointed a family liaison officer (FLO). Mr Maslennikovas’ had not
given any contact details for his next of kin when he arrived at Wandsworth, so the
FLO contacted the Lithuanian Embassy and the local police for assistance to
identify Mr Maslennikovas’ family and friends.
79. On 19 July, the Lithuanian Embassy contacted Mr Maslennikovas’ son to inform him
of Mr Maslennikovas’ death. Also, that day, the FLO took a call from a friend of Mr
Maslennikovas following contact from the police, who provided the contact details of
Mr Maslennikovas’ daughter, who was in the UK. Officer B, who spoke Lithuanian,
spoke to Mr Maslennikovas’ daughter later that day and, with the support of the
FLO, informed Mr Maslennikovas’ daughter her of her father’s death.The FLO
provided support to Mr Maslennikovas’ daughter and offered advice as to the next
steps.
80. The prison contributed towards Mr Maslennikovas’ funeral costs in line with national
policy.
Support for prisoners and staff
81. After Mr Maslennikovas’ death, the Head of Operations debriefed the staff involved
in the emergency response to ensure they had the opportunity to discuss any
issues arising, and to offer support. The staff care team also offered support.
82. The prison posted notices informing other prisoners of Mr Maslennikovas’ death
and offering support. Staff reviewed all prisoners assessed as being at risk of
suicide or self-harm in case they had been adversely affected by Mr Maslennikovas’
death.
Post-mortem report
83. The post-mortem report gave Mr Maslennikovas’ cause of death as ligature
compression of the neck and buprenorphine toxicity.
84. The post-mortem report noted that the concentration of buprenorphine present at
the time of Mr Maslennikovas’ death was significantly higher than that associated
with the target therapeutic range and was much higher than those concentrations
associated with recorded overdose episodes and in illicit drug users abusing
buprenorphine. It is not possible to determine how Mr Maslennikovas obtained the
buprenorphine because he had not been prescribed it at Wandsworth since October
2022.
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Findings
Assessment of risk
85. Prison Service Instruction (PSI) 64/2011, on safer custody, which was in place at
the time of Mr Maslennikovas’ death and since replaced by the Prison Safety
Framework, requires staff who have contact with prisoners to be aware of the risk
factors and triggers that might increase the risk of suicide and self-harm and take
appropriate action. Any prisoner identified as at risk of suicide or self-harm must be
managed under suicide and self-harm procedures (known as ACCT). Mr
Maslennikovas had multiple risk factors for suicide and self-harm. It was his first
time in prison, he had a history of self-harm, a history of substance misuse, had no
contact with his family and he was a foreign national prisoner who was due to be
extradited.
ACCT management
86. Mr Maslennikovas did not have a recent history of self-harm with the last reported
self-harm attempt 17 years earlier. However, on 12 July, Mr Maslennikovas made
substantial cuts to his left arm and staff appropriately opened an ACCT. There is no
evidence that staff used formal interpreting services at all during the ACCT process
(and we discuss this in more detail shortly) but Mr Maslennikovas said he had
harmed himself because he was under threat from other Lithuanian prisoners on
the wing.
87. The following morning, just 16 hours after staff began ACCT procedures, due to Mr
Maslennikovas’ presentation (well kempt and engaged well) and him saying he
would not self-harm again and he was no longer under threat, staff considered that
he was no longer at raised risk of suicide and self-harm and closed the ACCT. Mr
Maslennikovas said he no longer felt under threat but it is not clear that staff had
taken any steps to understand the nature of the threat or how he had managed to
resolve it so quickly (and essentially overnight while locked in his cell). There is no
evidence that the staff involved in closing the ACCT took into account any of Mr
Maslennikovas’ known risk factors.
88. Healthcare staff were not present at the ACCT review, and they had not apparently
assessed his mental health since his self-harm. The Head of Healthcare at
Wandsworth said that during the daily morning meeting, the mental health team is
given a list of prisoners who are on an ACCT and due for a case review. They then
decide which healthcare staff are best suited to attend each review that day and
inform wing staff. She said sometimes healthcare staff cannot attend the review, but
they will email the ACCT case manager with relevant information. She said that
sometimes, wing staff do not invite healthcare staff to the case reviews, and this
seems to be the case for Mr Maslennikovas.
89. On 14 and 15 July, Mr Maslennikovas displayed further unusual behaviour, burning
paper and smashing up his cell, and he said that he wanted a move off the wing.
On 15 July, he and his cellmate again smashed their cell and Mr Maslennikovas
asked to move to the CSU. Most of the staff who spoke to him about his behaviour
were seemingly unaware that his ACCT was in the post-closure phase and certainly
there is no evidence that they considered whether the ACCT should be reopened.
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90. Later, on 15 July, Mr Maslennikovas was moved to B wing (which was volatile at the
time). While we have not seen any particular evidence to suggest that he was in
crisis in the hours before his death, nor have we seen any particular evidence that
staff had taken steps to properly assess his risk at any time before that. We do not
consider that staff took steps to support Mr Maslennikovas or prevent his death in
any meaningful way.
Actions taken at Wandsworth since Mr Maslennikovas’ death
91. Mr Maslennikovas was the fourteenth prisoner at Wandsworth to take his life since
January 2020. Up to the end of November 2024, five more prisoners had taken their
life.
92. Wandsworth has been identified as requiring additional support due to the high
number of self-inflicted deaths that have occurred in a short period of time, the UN
from HMIP and a high profile escape in 2023 and HMPPS arranged for a task force
to help the prison. The action plan from the subsequent meetings has included work
on early days processes, quality assurance and case management training for
ACCTs and guidance for safety admin teams.
93. Wandsworth has put a number of other actions in place to help staff identify and
support prisoners who might be at risk of suicide and self-harm. This includes
introducing a single case management model for ACCT procedures, rebolstering
the Listeners programme (prisoners trained by the Samaritans to provide
confidential support), introducing a programme to train prisoners in mental health,
and promotion of Big Word interpreting services. In addition, we were told that, as of
February 2024, the Safer Custody team was fully staffed. This has resulted in the
team having around 500 contacts with prisoners a month.
94. In May 2024, we issued a recommendation to the then Governor that she provide
the Ombudsman with a clear plan of how she was addressing issues identified with
assessing and managing prisoners’ risk of suicide and self-harm. The prison
responded and said that a new, highly experienced Governor had been appointed
along with an additional temporary Deputy Governor for 12 months to strengthen
and inject experience into the Senior Leadership Team, and to provide a clear
vision for improving delivery and outcomes. The prison set out a number of other
planned measures to support improvement across a number of areas.
95. Given the well-evidenced difficulties Wandsworth faced at the time of Mr
Maslennikovas’ death and the targeted support the prison is now receiving, we
make no recommendation.
Interpreting services
96. Staff at Wandsworth have access to Big Word telephone interpreting service, which
is available 24-hours a day. Staff can telephone and request an interpreter in the
language needed. There are specific telephones (with two receivers) that can be
used to access the Big Word service to facilitate a three-way conversation.
97. We conclude that there is sufficient evidence in Mr Maslennikovas’ file to conclude
that he spoke very limited English and struggled to read and write in English. A
prison GP was the only person to record having used interpreting services for Mr
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Maslennikovas during his time at Wandsworth. There is no evidence that prison
staff considered using an interpreter at all. At times, Mr Maslennikovas asked his
cell mate to interpret for him, which is not always appropriate and poses risks,
such as confidentiality issues and potential for bullying and coercion.
98. It is difficult to see how staff could have had any meaningful conversations with
Mr Maslennikovas and captured adequate in-depth information about his health,
level of risk and concerns without the use of official interpreting services.
99. The clinical reviewer concluded that, while there are huge difficulties managing
the logistics of effective translation in an appropriate time frame for prisoners, Mr
Maslennikovas should have been seen in a clinical environment with an
independent form of translation of sufficient quality to ensure that he understood
his treatment options, particularly in relation to his substance misuse.
100. This is not the first time that we have raised concerns about staff’s failure to use
interpreting services for foreign national prisoners at Wandsworth.
101. Wandsworth have taken steps to promote interpreting services. Since February
2024, they have produced pocket cards for staff and have put posters around the
prison. They have also ensured that new prison staff receive information about
interpreting services at the point of their induction.
102. The new local foreign national strategy makes clear the instances when using
prisoners to interpret is not appropriate, such as when discussing offence details, or
personal and medical matters. It notes that Big Word is not being used frequently
enough and emphasises the importance of increasing its use.
103. In July 2024, we made a recommendation to about using a standardised approach
to interpreting services to better meet the needs of foreign national prisoners. The
prison responded that where a prisoner’s first language is not English, this is
recorded on arrival and a visual marker is placed in the medical records that
prompts the clinician to consider using interpreting services. Specially adapted
telephones are in all clinic rooms, and allow three-way telephone conversation, and
the Equalities Manager has commenced regular audits of telephone availability to
ensure that suitable phones are available for Big Word to be used.
104. Usage of the Big Word is monitored in the monthly Foreign National meeting, which
has been introduced in line with the new Foreign National Strategy to ensure the
prison is appropriately responding to the needs and risks of the large Foreign
National population, including language needs. Areas with low usage are reminded
of the importance of evidencing when interpreting services have been used.
105. Additional posts for foreign national peer mentors have been agreed, and Catch 22
will continue to provide support and mentoring to the reps. There has been a
concerted drive to recruit foreign national Listeners to ensure there is appropriate
support for the large foreign national cohort, and there are revisions being made to
the Listeners rota to include displaying the languages Listeners speak to provide
non-English speakers with a Listener they can communicate with. In light of
Wandsworth’s effort to increase the use of formal interpreting services, we make no
additional recommendations.
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Clinical care
Substance misuse care
106. Mr Maslennikovas was dependant on drugs in the community and said that he
misused alcohol when he was unable to access heroin. When he arrived at
Wandsworth, he was appropriately referred to substance misuse services and was
prescribed methadone as part of opiate substitution therapy, which was adequately
increased to manage his withdrawal symptoms. However, when Mr Maslennikovas
asked to reduce his methadone, the dose was decreased weekly, but substance
misuse staff did not review Mr Maslennikovas to see if he was coping or having any
symptoms of withdrawal.
107. Mr Maslennikovas also completed a 10-day buprenorphine detoxification
programme in October 2022. The clinician who gave Mr Maslennikovas his last
dose of buprenorphine should have added him to a list for review, but this did not
happen, and Mr Maslennikovas had no further engagement with substance misuse
services.
108. The toxicology report shows Mr Maslennikovas had a significant amount of
buprenorphine in his system. It is not possible to determine how Mr Maslennikovas
obtained the buprenorphine. But, given he had not been prescribed the drug since
October 2022, we suspect that he obtained it illicitly from another prisoner who was
prescribed it.
109. At the time of Mr Maslennikovas’ death, buprenorphine was issued in tablet form,
which unlike methadone (a liquid), could be concealed in the mouth and then
potentially traded within the prison. A non-medical prescriber at Wandsworth said
that Wandsworth is changing from prescribing buprenorphine in tablet form to
injection to reduce the risk of illicit trading.
110. The clinical reviewer said that the healthcare system at present does not appear to
have a failsafe in the form of a simple audit to check which patients have been
reviewed at the end of the detoxification programme and a clear record made of
advice given. This may be particularly challenging in a remand prison but is an
essential part of good clinical practice. We recommend:
The Head of Healthcare and the Substance Misuse Lead should ensure that
there is a system in place to provide follow up appointments for prisoners
undertaking an opiate detoxification programme and includes a failsafe to
ensure staff are alerted to those who have not been reviewed at the end of the
programme.
111. Mr Maslennikovas told a substance misuse worker in June 2022 that he would
abuse alcohol when he could not access heroin. This was documented in his
healthcare record but there is no evidence that it was shared with prison staff.
When a large quantity of fermenting liquid was found in Mr Maslennikovas’ cell in
December 2022, this information was not shared with healthcare staff or the
substance misuse team and so no action was taken to support his substance
misuse needs.
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112. The clinical reviewer noted that possession of alcohol is a potential health risk in
prisoners who have substance misuse problems. There appears to be no system, in
a prison with significant numbers of prisoners who have substance misuse
problems, to alert healthcare to those who may be misusing alcohol or for
healthcare staff to alert prison staff of any concerns about prisoners whose use of
alcohol may indicate a more significant level of abuse. We recommend:
The Governor and Head of Healthcare should identify the best way to share
intelligence and manage risk around alcohol misuse in those with substance
misuse problems.
113. The clinical reviewer concluded that, overall, Mr Maslennikovas’ access to
substance misuse services at Wandsworth was equivalent to what he could have
expected in the community, but the follow-up care fell below what he could have
expected. She also noted that issues with record keeping (not all substance misuse
engagement was entered into his healthcare record), and interpreting services
made it impossible to determine if the overall clinical care Mr Maslennikovas
received at Wandsworth was equivalent to what he could have expected in the
community. The clinical reviewer makes other recommendations not related to Mr
Maslennikovas’ death that the Head of Healthcare will wish to address.
Key worker scheme
114. There is no evidence in Mr Maslennikovas’ prison record that wing staff had any
meaningful interactions with him. Because of staffing levels, and to provide the best
regime and access to purposeful activity, key work at Wandsworth had been
suspended since the COVID-19 pandemic. As a result, Mr Maslennikovas did not
have a key worker during his time at Wandsworth. While we cannot say that Mr
Maslennikovas would have engaged with staff, particularly if they did not use
interpreting services, staff missed opportunities to have welfare conversations with
Mr Maslennikovas and to support him with any concerns he might have had.
115. Since Mr Maslennikovas’ death, Wandsworth have implemented a process to
ensure that all prisoners have a quality conversation with a member of staff, and a
case note entry, at least once a month. This is being monitored by monthly checks
and staff are required to follow up on any prisoner without case notes. We
understand that, as part of this process, custodial managers are required to dip test
case notes to quality assess these. As a result of these changes, we do not make a
recommendation.
Inquest
116. The inquest into Mr Maslennikovas’ death concluded on 27 May 2026 and a jury
returned a verdict of suicide.
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