Baltrunas, Karolis

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Karolis
Baltrunas, a prisoner at HMP
The Mount, on 27 August 2020
A report by the Prisons and Probation Ombudsman
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Karolis Baltrunas died on 27 August 2020, after being found hanging in his cell in the
segregation unit at HMP The Mount. He was 31 years old. I offer my condolences to Mr
Baltrunas’ family and friends.
Mr Baltrunas was facing deportation to Lithuania and he was resistant to this, although his
reasons remain unclear. I am concerned that there is no evidence that staff recognised
that the uncertainty about this may have affected his mental wellbeing.
By the time of his death, Mr Baltrunas had been in the segregation unit for 52 days. I am
concerned that there is no evidence that staff had any meaningful contact with him during
this time, and that mandatory procedures for segregated prisoners were not followed: he
did not have a designated officer and a care plan was not put in place to support his
mental health. In addition, although Mr Baltrunas’ English was poor, a translation service
was not always used for some significant and sensitive discussions with him (such as
segregation reviews).
I am extremely concerned that staff did not start suicide and self-harm procedures when
Mr Baltrunas harmed himself on 24 August.
I am also concerned about events on the morning of Mr Baltrunas’ death. He should have
been checked at around 5.30am, but the officer who claimed to have made that check
failed to do so. Another officer checked him at 7.10am and did not notice anything
untoward, although Mr Baltrunas was almost certainly already hanging. Then, when he
was found hanging at 8.15am, staff attempted to resuscitate him even though there were
clear signs he was dead.
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 November 2023
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
Summary
Events
1. On 17 May 2019, Mr Karolis Baltrunas, a Lithuanian national, was remanded to HMP
Bedford charged with conspiracy to steal motor vehicles. He was later sentenced to
three years and four months in prison and transferred to HMP The Mount.
2. On 3 July 2020, Mr Baltrunas refused to move to an Immigration Removal Centre
prior to being deported to Lithuania.
3. On 7 July 2020, Mr Baltrunas was moved to the segregation unit for threatening two
officers. While in the segregation unit, Mr Baltrunas damaged his cell and
threatened officers.
4. On 24 August, Mr Baltrunas damaged his cell and was moved to a new cell through
a planned use of force. Mr Baltrunas had cuts to his arm and neck and a nurse said
at the debriefing meeting that his cuts were self-inflicted. Despite this, staff did not
start Prison Service suicide and self-harm procedures (known as ACCT).
5. At 7.10am on 27 August, an officer checked the prisoners in the segregation unit.
She said that when she checked on Mr Baltrunas, she believed he was alive and
standing in the middle of his cell. When other staff checked Mr Baltrunas at
8.15am, they found him hanging from the ceiling light. There were clear signs that
rigor mortis had started to set in (rigor mortis is stiffening of the body that occurs
after death), however officers and a nurse attempted to resuscitate Mr Baltrunas
until ambulance paramedics arrived and confirmed that he was dead.
Findings
Segregation
6. Mr Baltrunas was segregated for 52 days before his death. He was not managed in
line with national requirements for prisoners held in segregation. He did not have a
designated officer and there is no evidence that staff had any meaningful contact
with him during this time. In addition, there was no care plan in place to support his
mental health.
ACCT
7. Mr Baltrunas repeatedly asked staff for information about his deportation. There is
no evidence that staff recognised that the uncertainty about this might affect Mr
Baltrunas’ mental wellbeing.
8. Staff should have started ACCT procedures after Mr Baltrunas harmed himself on
24 August.
Response on 27 August
9. Mr Baltrunas was not checked at 5.30am, as he should have been.
10. It seems probable that Mr Baltrunas was hanging when Officer B checked him at
7.10am and believed that he was alive.
Prisons and Probation Ombudsman 1
11. When Mr Baltrunas was found hanging, staff attempted to resuscitate him despite
the fact that there were clear signs that he had been dead for some time.
Translation
12. We are concerned that, although Mr Baltrunas’ English was poor, some significant
and sensitive discussions, including some segregation reviews and his mental
health assessment initially took place without the use of a translation service.
Recommendations
• The Governor and Head of Healthcare should ensure that staff manage prisoners
held in the segregation unit in line with national policy set out in PSO 1700,
including ensuring that:
• a designated officer is allocated to each prisoner;
• the designated officer has purposeful dialogue each day with his or her allocated
prisoners;
• a minimum of three quality entries are recorded each day for each prisoner; and
• staff create a mental health care plan for all prisoners segregated for more than
30 days.
• The Governor and Head of Healthcare should ensure that staff manage prisoners at
risk of suicide or self-harm in line with national guidelines, including, in particular,
that an ACCT is opened following all acts of self-harm.
• The Governor should ensure that staff completing roll checks satisfy themselves
that prisoners are alive and well.
• The Governor should share a copy of this report with Senior Manager A, CM A, CM
B, CM C, CM D, SO A and Officer B and arrange for a senior manager to discuss
the Ombudsman’s findings with them.
• The Governor and Head of Healthcare should ensure that staff are given clear
guidance about the circumstances where resuscitation is and is not appropriate, in
line with national and European guidelines.
• The Head of Healthcare should share a copy of this report with Nurse B and Nurse
C and arrange for their clinical supervisors to discuss the Ombudsman’s findings
with her.
• The Governor and Head of Healthcare should ensure that staff use a translation
service when discussing sensitive or complex matters with prisoners who do not
speak English well.
2 Prisons and Probation Ombudsman
The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP The Mount informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
14. The investigator obtained copies of relevant extracts from Mr Baltrunas’ prison and
medical records. She interviewed 17 members of staff at The Mount between
November 2020 and January 2021. All the interviews were conducted by telephone
due to revised working practices during the COVID-19 pandemic. The investigation
was subsequently reallocated to one of the investigator’s colleagues. He
interviewed one further witness, also by telephone.
15. NHS England commissioned a clinical reviewer to review Mr Baltrunas’ clinical care
at the prison. The investigator and clinical reviewer jointly interviewed clinical staff.
16. We informed HM Coroner for Hertfordshire of the investigation. The Coroner gave
us Mr Baltrunas’ cause of death. We have given the Coroner a copy of this report.
17. One of the Ombudsman’s family liaison officers contacted Mr Baltrunas’ partner,
and his aunt and uncle, to explain the investigation and to ask if the family had any
matters they wanted the investigation to consider. Mr Baltrunas’ aunt said that she
had had concerns about her nephew’s mental health and the family solicitors had
written to the prison to explain this. Mr Baltrunas’ aunt also said that she had left
messages on the prison’s safer custody hotline on 12 and 13 July 2020, but her
calls were not returned.
18. We shared our initial report with Mr Baltrunas’ family and with HMPPS. Mr
Baltrunas’ mother said that the living conditions at The Mount were poor, and her
son’s mental health had deteriorated. She also said that the prison paid for her
son’s body to be repatriated, but they did not contribute to the costs of the funeral.
Mr Baltrunas’ aunt said that her nephew’s date of birth was 12 January 1989, and
not 31 January 1985 as the medical records indicate. HMPPS provided additional
information about roll checks on the morning of Mr Baltrunas’ death and pointed out
that our finding and recommendation about officers speaking to prisoners at the
time of the 7.10am was not in line with national policy. HMPPS also pointed out
that we had mistaken the roles of two of the staff referred to in our report. We have
made changes to this report as appropriate.
Prisons and Probation Ombudsman 3
Background Information
HMP The Mount
19. HMP The Mount is a medium security prison holding approximately 1,000 men.
Hertfordshire Community NHS Trust provides primary healthcare and GP services.
Hertfordshire Partnership University NHS Foundation Trust provides mental health
services.
HM Inspectorate of Prisons
20. The most recent full inspection of HMP The Mount was in May 2018. Inspectors
found that governance of segregation was weak. Inspectors reported that targets
set for prisoners were generic with no evidence of individual care plans and that
integration planning was underdeveloped and that not enough prisoners returned to
normal location. Inspectors noted that electronic case notes were used as the sole
record of prisoner behaviour, that there were too many missing entries, and those
conducting segregation review meetings did not have enough information to inform
their decisions. Inspectors made a recommendation for appropriate oversight of the
segregation unit to ensure prisoners did not stay on the unit any longer than
necessary.
21. Inspectors found that records made for prisoners identified at risk of suicide and
self-harm suggested good care for prisoners identified as being at risk.
22. Inspectors note that relationships between staff and prisoners had deteriorated
since the previous inspection with only 55% of prisoners saying that staff treated
them with respect.
23. HMIP returned to The Mount in April 2019 to conduct an Independent Review of
Progress against the key recommendations following the 2018 inspection. They
noted that the prison appeared to be on an upward trajectory, albeit from a very low
base, and that good or reasonable progress had been made against seven of the
13 key recommendations.
24. However, they found that insufficient progress had been made in relation to some
aspects of safety and that, in particular, the governance of segregation remained
weak. An assurance checklist was in place to help ensure that paperwork was
completed, but every form that inspectors checked was blank. Good order and/or
discipline (GOOD) reviews had taken place but without any meaningful targets
being set. They found no evidence of reintegration planning for any segregated
prisoners, although since the last inspection, there had been a steady decrease in
the number of days that prisoners spent segregated.
Independent Monitoring Board
25. 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 February 2021, the IMB reported
that the Governor and staff had worked intelligently and diligently to keep the
COVID-19 pandemic at bay. However, controlling the pandemic came at a price
paid by the prisoners held in the prison. The Mount was always able to provide
prisoners with the maximum time out of cell permitted by the national restrictions
4 Prisons and Probation Ombudsman
but, nonetheless, for much of the year prisoners had not had adequate time out of
their cells.
26. Despite this, the prisoners in the segregation hardly had any complaints about their
treatment in the unit. The Board reported that all the prisoners who were entitled to
reviews (those on good order and discipline (GOOD) and own protection) received
regular reviews in the presence of a governor, an IMB member and a healthcare
representative. During the lockdown the IMB member had attended the reviews by
telephone conferencing when they were unable to attend in person. There had been
an improvement in the segregation paperwork, with a better record of previous
reviews.
Previous deaths at HMP The Mount
27. Mr Baltrunas was the third prisoner to die at The Mount since June 2017. Of the
previous deaths, one was from natural causes, and one was from illicit drug and
alcohol use. There were no similarities between Mr Baltrunas’ death and the
previous deaths.
Segregation units
28. Segregation units are used to keep prisoners apart from other prisoners. This can
be because they feel vulnerable or under threat from other prisoners (known as
‘own protection’) or if they behave in a way that prison staff think would put people
in danger or cause problems for the rest of the prison (known as ‘good order and
discipline’ – GOOD). They also hold prisoners serving punishment of cellular
confinement after disciplinary hearings.
29. Segregation is authorised by an operational manager at the prison who has to be
satisfied that the prisoner is fit for segregation after an assessment by a member of
healthcare staff. Segregation unit regimes are usually restricted, and prisoners are
permitted to leave their cells only to collect meals, wash, make phone calls and
have a daily period in the open air. The unit at The Mount is known as the Care
and Separation Unit (CSU) and comprises 22 cells.
Assessment, Care in Custody and Teamwork
30. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses for supporting and monitoring prisoners assessed as at risk
of suicide and self-harm. The purpose of the ACCT process is to try to determine
the level of risk posed, the steps that might be taken to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Levels of supervision and
interactions are set according to the perceived risk of harm. There should be
regular multi-disciplinary case reviews involving the prisoner. Checks made on
prisoners should be at irregular intervals to prevent the prisoner anticipating when
they will occur. Part of the ACCT process involves assessing immediate needs and
drawing up a caremap to identify the prisoner’s most urgent issues and how they
will be met. Guidance on ACCT procedures is set out in Prison Service Instruction
(PSI) 64/2011.
Prisons and Probation Ombudsman 5
Key Events
31. On 17 May 2019, Mr Karolis Baltrunas was remanded to HMP Bedford charged with
conspiracy to steal motor vehicles. Mr Baltrunas was a Lithuanian national and this
was his first time in prison in the UK. In July, Mr Baltrunas was sentenced to three
years and four months in prison.
32. On 18 July, Mr Baltrunas was transferred to HMP The Mount.
33. At his healthcare reception screen, Mr Baltrunas said that he had never tried to
harm himself in the past and that he had no present thoughts of self-harm or
suicide. The nurse noted that Mr Baltrunas declined the use of an interpreter as he
spoke enough English to “get by”. At a second healthcare assessment the following
day, another nurse noted that Mr Baltrunas had no indications of mental illness.
34. In August 2019, Mr Baltrunas was notified that he was going to be deported. On 3
July 2020, he was due to move to an Immigration Detention Centre ahead of a
deportation flight to Lithuania. However, he refused to leave his cell and his
deportation was cancelled. Mr Baltrunas was placed on a disciplinary charge for
refusing a lawful order.
35. On 6 July, Mr Baltrunas was placed on disciplinary charge for threatening two
officers after he was asked to return to his cell. One of the officers wrote in the wing
observation book that Mr Baltrunas took up a boxing stance and clenched his fists.
36. On 7 July, the Head of Residence gave authority for Mr Baltrunas to be segregated
under Prison Rule 45, with a review date of 10 July. Prison Rule 45 permits the
segregation of prisoners for the maintenance of good order or discipline (GOOD).
She gave as the reason for segregation that “Mr Baltrunas’ behaviour continued to
be threatening towards staff. This is part of an established pattern of poor
behaviour …”.
37. A nurse completed an initial segregation health screen that day and noted that Mr
Baltrunas showed no signs of being acutely unwell and that he would be able to
cope with a period of segregation.
38. Mr Baltrunas had a segregation review on 10 July which was chaired by the Head
of the CSU. He noted that Mr Baltrunas’ behaviour had continued to be threatening
towards staff since being in the CSU and that he consistently behaved in an
aggressive manner. He authorised Mr Baltrunas to remain segregated until 17 July
and Mr Baltrunas was given specific targets to improve his behaviour.
39. On 13 July, Mr Baltrunas punched another prisoner as he was being escorted to
exercise. He told an officer that he had punched the prisoner for training. Mr
Baltrunas was taken back to his cell.
40. A manager chaired Mr Baltrunas’ segregation review on 17 July. He noted that Mr
Baltrunas had refused a voluntary flight to Lithuania the previous week. Mr
Baltrunas asked whether he would be arrested on return to Lithuania, but the
manager told him that he could not answer that question as it was not connected
with matters related to United Kingdom interests. Mr Baltrunas’ next segregation
review was set for 31 July.
6 Prisons and Probation Ombudsman
41. Later that evening, Mr Baltrunas flooded his cell and the landing by blocking his
hand basin and running the taps. When challenged, Mr Baltrunas said that he
could not speak English. (Staff who dealt with Mr Baltrunas said they believed that
his understanding and ability to speak English was better than he sometimes tried
to imply.)
42. On 19 July, officers were escorting Mr Baltrunas back to his cell from the exercise
yard when he backed into the library area of the unit and took up a boxing stance.
He then crouched to the floor and wrapped his arms around his body. Officers then
placed him in handcuffs and returned him to his cell.
43. On the morning of 20 July, a prison GP saw Mr Baltrunas during a routine visit to
the CSU. He noted that Mr Baltrunas said he was stressed and anxious. The GP
noted that he spoke to a mental health nurse, and he told the investigator that he
spoke to Nurse A.
44. On 20 July, Mr Baltrunas smashed his cell door observation panel. When an officer
asked him why he had broken the panel, Mr Baltrunas just laughed. Following this
incident, Mr Baltrunas’ unlock level was increased to a minimum of two officers.
This was later increased to three officers.
45. On 21 July, Nurse A noted that Mr Baltrunas appeared fit and well and was
medically fit to be held in the CSU. The nurse made no reference to the GP’s note
in the records made the previous day.
46. While being escorted back to his cell from exercise on 23 July, Mr Baltrunas ran
away from staff, who then had to restrain him to take him back to his cell.
47. On 26 July, a nurse was asked to review Mr Baltrunas’ mental state. The nurse
noted that an assessment was not possible due to language difficulties and the risk
Mr Baltrunas posed. However, he also noted that Mr Baltrunas was calm and
stable. The nurse noted that Mr Baltrunas denied being stressed, although he also
said that some days he was happy and some days he was sad.
48. On 27 July, Mr Baltrunas asked an officer if he could have some work to do, and
also asked for a radio and TV. He was told that none of these things would be
possible unless his behaviour improved. The officer noted that it was sometimes
difficult to talk to Mr Baltrunas because of the language barrier, but that he seemed
to understand.
49. On 30 July, Mr Baltrunas’ told his offender supervisor that he did not know what
was happening with his deportation and that he did not want to be deported as he
had family in the UK. The offender supervisor said that the immigration agency held
immigration surgeries at The Mount, and he would email them to contact Mr
Baltrunas when they next visited. (There is no evidence that this was followed up.)
50. At a segregation review on 31 July, a prison manager wrote that Mr Baltrunas had
continued to be aggressive and threatening towards staff. Mr Baltrunas’ next
segregation review was set for 14 August.
51. On 8 August, an officer escorted Mr Baltrunas to the showers. After he had
showered, Mr Baltrunas asked for a clean T-shirt. The officer told Mr Baltrunas that
he would take him back to his cell and then try to find him a T-shirt. However, Mr
Baltrunas shouted that he wanted a clean T-shirt there and then, and he threw a
Prisons and Probation Ombudsman 7
punch at the officer. The punch missed and the officer, assisted by colleagues,
pushed Mr Baltrunas back into his cell.
52. At Mr Baltrunas’ segregation review on 14 August, a prison manager noted that Mr
Baltrunas denied attempting to assault the officer the previous week. He also said
that he was not the person that the immigration services believed him to be and that
he would not be deported. She decided that Mr Baltrunas should remain
segregated, and she set his next review for 28 August.
53. Prison Service Rules require additional authority where a prisoner is segregated for
a continuous period of 42 days. The authority must be given on behalf of the
Secretary of State by a Prison Group Director (Deputy Director of Custody at the
time). On 15 August, authority was given for Mr Baltrunas’ segregation beyond 42
days. The reasons and plans for Mr Baltrunas’ segregation were given as:
“Mr Baltrunas’ behavior since being in the CSU has been poor for much of the
time. He has refused to return to his cell, assaulted another prisoner, attempted
to assault staff and been restrained on multiple occasions. He attempts to bully
and intimidate staff with his size and is regularly rude to staff. At this point his
behaviour is not suitable for normal location, especially with an impending
deportation date of 24/08/2020.
“There is currently no plan to return Mr Baltrunas to normal location, he will be
deported from the CSU on 24/08/2020. This will allow immigration staff to have
more control when they come to collect him and also protect staff on normal
location up until his deportation.”
54. On 17 August, an officer noted that Mr Baltrunas had been “acting very strange
throughout the day”, asking to see people but not explaining why, and that he had
put in a number of applications, mainly about his deportation.
55. Mr Baltrunas continued to be disruptive throughout 19 to 21 August, during which
time he caused severe damage to his cell, damaged a shower door, flooded the
landing and threatened staff with a weapon.
56. A prison manager told the investigator that he had a number of conversations with
Mr Baltrunas during his time in the CSU. He said that Mr Baltrunas’ behaviour was
erratic, and he would often be challenging and unpredictable. He said that the early
thoughts were that Mr Baltrunas would remain segregated until his deportation as
the initial belief was that his deportation would be imminent. However, the
deportation dates kept changing so Mr Baltrunas would have returned to normal
location if his behaviour had improved. He said that Mr Baltrunas sometimes said
that he could not understand what he was being told so the prison began to use
Language Line (a telephone translation and interpretation service) at all of his
segregation reviews.
57. On 23 August, a prison manager recorded that Mr Baltrunas had asked to speak to
immigration staff and that she had asked the CSU staff to chase this up.
58. On 24 August, Mr Baltrunas damaged his cell, and he was noted to be aggressive
and non-compliant. A planned intervention was arranged to move him to a new
cell. Staff went to his cell to tell him about the move, and he was asked if he would
comply. He said that he would, and he was warned that he would be restrained if
he resisted. Mr Baltrunas remained compliant, and he was escorted to a new cell.
8 Prisons and Probation Ombudsman
Body-worn video (BWV) footage shows that Mr Baltrunas had cuts to his right arm
and to the left side of his neck.
59. The staff who attended the debriefing meeting following the intervention were: a
Senior Manager A, Custodial Manager (CM) A, CM B, CM C, CM D, Senior Officer
(SO) A, an Operational Support Grade (OSG), and two nurses. At the meeting
Nurse B said that the cuts to Mr Baltrunas’ neck were self-inflicted, and in her entry
in Mr Baltrunas’ medical record she noted that he had made self-harm cuts to his
neck and arm. Although she described most of the cuts as superficial, one to Mr
Baltrunas’ arm required cleaning, gluing and steristrips. (An officer who was not
involved in the intervention recorded that the cuts occurred accidentally when Mr
Baltrunas damaged his cell.)
60. At interview with the investigator, Nurse B said that Mr Baltrunas did not disclose to
her how his injuries occurred, but their appearance was consistent with self-harm
wounds. In answer to a question on why she did not begin ACCT procedures, she
said that she checked Mr Baltrunas’ medical record and saw that he had no history
of self-harm. She said that prisoners in the CSU were checked more closely than
prisoners on the standard prison wings, so she did not think that an ACCT was
necessary.
61. On 25 August, staff noted that Mr Baltrunas’ planned deportation on the previous
day had been cancelled, and that Mr Baltrunas had “been acting very strange
throughout the day”.
26 August
62. At 9.01am on 26 August, a senior manager saw Mr Baltrunas during a standard visit
to the CSU as duty governor. Mr Baltrunas said that he was okay, but he asked to
speak to her later on. She arranged a room and a call to Language Line and saw
Mr Baltrunas that afternoon. She told the investigator that Mr Baltrunas asked why
he was being kept in the CSU and she explained that it was due to his behaviour
and that he would be able to return to normal location if he stopped contravening
rules and posing a threat to staff. She said the meeting lasted around 15 minutes
as the conversation seemed to go round in circles. Eventually the Language Line
translator ended the call as Mr Baltrunas was being rude and abusive.
63. At 7.01pm, an officer noted that Mr Baltrunas had damaged his wash basin.
64. At around 8.30pm, Officer A carried out the final roll check for the day. After Mr
Baltrunas’ death, he wrote a statement to say that when he made his check, Mr
Baltrunas was standing at his cell door, and he asked for a newspaper. He that he
told Mr Baltrunas, as he had told him the two previous nights, that he was not
permitted to pass prisoners any items during the night patrol state. He wrote that
Mr Baltrunas seemed disappointed, but he accepted what he was told.
Prisons and Probation Ombudsman 9
27 August
65. Officer A should have carried an early morning roll check at 5.30am on 27 August.
He said in his statement that Mr Baltrunas’ cell was very dimly lit, but that he saw a
shape under the bed clothes which he assumed was Mr Baltrunas, and he moved
on to the next cell.
66. At around 7.10am, Officer B arrived in the CSU. Officer A briefed her, and he left
the unit. Officer B made a check of the prisoners. She told the investigator that
when she checked Mr Baltrunas, he appeared to be standing around the middle
area of the cell and facing left. She said that he had placed something at the cell
window to reduce the amount of light coming into the cell but there was enough light
for her to see, so she did not switch on the cell light. She said that she normally
greeted prisoners who were awake, although she did not do so that morning. She
said that she thought she saw a slight movement in Mr Baltrunas’ left hand to
acknowledge her presence.
67. From around 8.00am, staff began letting prisoners out of their cells one-by-one so
they could collect their breakfast packs. Due to his behaviour, three officers needed
to be present whenever Mr Baltrunas was unlocked. At around 8.15am, three
officers went to Mr Baltrunas’ cell. Officer C looked through the observation panel
and saw Mr Baltrunas hanging from the light fixture with his feet off the ground. He
shouted that it was a ‘code blue’ (meaning that a prisoner is not breathing or having
difficulty breathing) and one of his colleagues radioed a medical emergency call.
The control room called an ambulance immediately.
68. Officer C unlocked the cell and he and another officer supported Mr Baltrunas’ body
while a third officer stood on the bed and cut the ligature, which had been made
from a bed-sheet. The officers lowered Mr Baltrunas to the cell floor.
69. An officer had entered the cell, and he noted that Mr Baltrunas’ eyes were open and
fixed and that his body was cold and stiff. He checked Mr Baltrunas for a heartbeat
but found none. The governing Governor, who was in the CSU making a standard
duty governor’s check of prisoners, instructed an officer to start cardiopulmonary
resuscitation (CPR).
70. Two nurses arrived within one or two minutes of hearing the code blue alarm.
Nurse C said that an officer was carrying out CPR. She noted that Mr Baltrunas
was ashen in colour and unresponsive. She checked Mr Baltrunas with a
defibrillator, which advised that no shock could be given. As officers continued to
give CPR, she tried to insert an airway to help give oxygen but could not do so as
Mr Baltrunas’ teeth were clenched, and his jaw muscles were rigid. Another nurse
arrived, and she inserted a nasal airway. Staff continued giving CPR and oxygen
until ambulance paramedics arrived.
71. An emergency ambulance had been called when the code blue call was made, and
paramedics reached the cell at around 8.32am. They declared Mr Baltrunas dead
around one minute later.
10 Prisons and Probation Ombudsman
Contact with Mr Baltrunas’ family
72. Mr Baltrunas had named his partner as next-of-kin and gave her address as a home
in the UK. In line with Government advice on COVID-19 working practices, an
administration team manager tried to telephone Mr Baltrunas’ partner at 11.00am
but got no response. She noted that the dial tone indicated that the number was an
international number. She made several further attempts to contact Mr Baltrunas’
partner, and then telephoned the Lithuanian embassy to see if they could help. At
12.20pm, she telephoned Mr Baltrunas’ aunt and informed her of the news. Later
that afternoon she also spoke to Mr Baltrunas’ uncle, and he passed on the news to
Mr Baltrunas’ partner.
73. Mr Baltrunas’ body was repatriated to Lithuania and The Mount contributed to the
costs for this.
Support for prisoners and staff
74. Two senior managers held a hot debrief with the staff and the staff care team also
offered support.
75. The prison posted notices informing other prisoners of Mr Baltrunas’ 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 Baltrunas’ death.
Cause of death
76. The pathologist gave Mr Baltrunas’ cause of death as suspension (hanging).
77. Toxicology tests found no evidence of the use of illicit substances.
Other matters
78. The investigator asked the prison about the concerns raised by Mr Baltrunas’ aunt.
The prison said that two messages had been left on the safer custody hotline
saying that Mr Baltrunas’ wife was anxious as she had not heard from him, and that
the safer custody team had contacted wing staff to pass these messages to Mr
Baltrunas. The prison was not able to provide the investigator with any letter from
Mr Baltrunas’ solicitors expressing concern about his mental health.
Prisons and Probation Ombudsman 11
Findings
Segregation
79. Prison Service Order 1700, Segregation, sets out the process that should be
followed when a prisoner is segregated. In the introduction, the PSO notes that in
the period 2001 to 2006, self-inflicted deaths in segregation settings, including
those segregated on normal location, accounted for 12% of all self-inflicted deaths
in prison. The PSO goes on to say that:
“Those prisoners who are the most ‘difficult’ are often the most vulnerable …
Staff are undoubtedly faced with difficult decisions as to where to hold some
prisoners and frequently care for prisoners in segregation units when all other
options have been exhausted. However, there have been cases where
prisoners have been held in segregation units and the justifications for doing so
have not been convincing. There have been cases where alternative options to
segregation have not been adequately explored.”
80. Processes contained in the PSO include that:
“A designated/personal officer is to be allocated to each prisoner … The
designated officer should engage [in] purposeful dialogue and record this on the
segregation history sheet. At least 3 quality entries are required daily …”
and
“Those segregated for more than 30 days should be subject to care plans that
detail how their mental well-being is to be supported.”
81. Segregation is an extreme and isolating form of custody. It inherently reduces
protective factors against suicide and self-harm, such as activity and interaction with
others. By the time of his death, Mr Baltrunas had been segregated for a
continuous period of 52 days. Apart from exercise, showers and the occasional
visit, he did not leave his cell. He had no radio or TV, no contact with other
prisoners, and for most of the time he was unlocked by three prison officers.
82. From the records provided, it would seem that poor and uncooperative behaviour
became the established pattern for him. We also note that he was clearly resistant
to the plans for his deportation, so we can understand why the prison considered
that the most pragmatic way forward was to keep him in the CSU until he was
remanded into the care of immigration staff, which was anticipated to take place on
24 August.
83. However, we are concerned that insufficient efforts were made to establish any
understanding of Mr Baltrunas and the concerns he might have had about his
deportation. The PSO requires that an officer should have been allocated as his
designated officer and should have had purposeful dialogue with him making three
quality entries in his records each day. There is no record of any such meaningful
interaction with him which might have helped in improving his behaviour or
understanding his mood.
84. In addition, we are very concerned that when Mr Baltrunas passed 30 days in
segregation, no care plan was created for him to help support his mental health.
Again, this might have helped in establishing meaningful dialogue with him.
12 Prisons and Probation Ombudsman
85. We make the following recommendations:
The Governor and Head of Healthcare should ensure that staff manage
prisoners held in the segregation unit in line with national guidelines,
including ensuring that:
• a designated officer is allocated to each prisoner;
• the designated officer has purposeful dialogue each day with his or her
allocated prisoners;
• a minimum of three quality entries are recorded each day for each
prisoner; and
• staff create a mental health care plan for all prisoners segregated for
more than 30 days.
Deportation
86. Mr Baltrunas repeatedly asked staff in the CSU what was happening about his
deportation. Although it would not have been possible for staff to tell him when he
was going to be deported, we consider that they could have done more to ensure
that he received information about the process and had an opportunity to discuss
his concerns. We are also concerned that there seems to have been no recognition
that the uncertainty about his future was likely to have an impact on Mr Baltrunas’
mental wellbeing.
Assessment, Care in Custody and Teamwork (ACCT)
87. On 24 August, staff assembled for a planned intervention to move Mr Baltrunas to a
new cell after he damaged his previous cell. BWVC footage clearly shows cuts to
Mr Baltrunas’ arm and neck as he was being escorted to his new cell. At the
debriefing meeting following the intervention, Nurse B said that the cuts to his neck
were self-inflicted. She said she did not start ACCT procedures because Mr
Baltrunas had no history of self-harm. The only reference to the cuts made by
prison staff was the note made by an officer, who wrote that the cuts were caused
accidentally.
88. We are very concerned that none of the prison staff thought it necessary to begin
ACCT procedures. All the staff involved in the intervention would have seen the
injuries, and they all attended the debriefing meeting when Nurse B said the injuries
were self-inflicted.
89. Nor do we understand Nurse B’s rationale in deciding not to open an ACCT.
Whether or not Mr Baltrunas had self-harmed in the past, he had self-harmed on
this occasion, and there is more to the ACCT procedures than being checked
regularly: they are also about trying to identify the cause of the prisoner’s distress
and putting support in place.
90. We make the following recommendations:
The Governor and Head of Healthcare should ensure that staff manage
prisoners at risk of suicide or self-harm in line with national guidelines,
including, in particular, that an ACCT is opened following all acts of self-harm.
Prisons and Probation Ombudsman 13
The Governor should share a copy of this report with Senior Manager A, CM
A, CM B, CM C, CM D and SO A and arrange for a senior manager to discuss
the Ombudsman’s findings with them.
The Head of Healthcare should share a copy of this report with Nurse B and
arrange for her clinical supervisor to discuss the Ombudsman’s findings with
her.
Roll checks
91. Roll checks are primarily a security check to count prisoners to ensure that they are
present in their cells, but they are also an opportunity for any concerns about a
prisoners’ safety to be identified and managed.
92. Following Mr Baltrunas’ death an officer wrote a statement to say that he checked
the prisoners in CSU at 5.30am on 27 August and he saw a shape under the
bedclothes in Mr Baltrunas’ cell, which he assumed to be Mr Baltrunas.
93. The investigator was later advised that the prison checked CCTV footage and found
that the officer did not conduct a roll check as he claimed. Following a prison
investigation and disciplinary hearing, the officer was given a final written warning
and was demoted to the rank of officer support grade (OSG). As the prison has
dealt with this matter, we make no recommendation of our own.
94. Officer B relieved the officer at 7.10am and said that when she made her roll check,
she saw Mr Baltrunas standing in the middle of his cell and that she saw nothing to
cause her concern.
95. Staff are not required to speak to prisoners when making roll checks if they have no
obvious concerns for the prisoners’ welfare. However, we note that when Mr
Baltrunas was discovered hanging at around 8.15am, he appears to have been in
the same position in the middle of the cell and, when checked, his body was cold
and rigor mortis had begun to set in. If Mr Baltrunas was already hanging when
Officer B made her check, this means that she failed to notice the ligature. We
cannot say for certain whether she failed to notice a ligature, or whether an earlier
discovery would have altered the outcome for Mr Baltrunas. However, we make the
following recommendations:
The Governor should ensure that staff completing roll checks satisfy
themselves that prisoners are alive and well.
Emergency response
96. In September 2016, Professor Sir Bruce Keogh, the National Medical Director at
NHS England, wrote to the Heads of Healthcare for prisons in England and Wales
to introduce new guidance to support staff on when not to perform CPR. This
guidance was designed to address the issue of inappropriate resuscitation after a
sudden death in prison and was taken from the European Resuscitation Council
Guidelines 2015 which state: “Resuscitation is inappropriate and should not be
provided when there is clear evidence that it will be futile.” The guidelines give
examples of futility as including the presence of rigor mortis. Attempting
resuscitation when someone is clearly dead is distressing for staff and undignified
for the deceased.
14 Prisons and Probation Ombudsman
97. The officer who started chest CPR at the instruction of the governing Governor, said
that Mr Baltrunas was not breathing, his eyes were open and fixed, and his body
was stiff. We also note that Nurse C was unable to insert an airway as Mr
Baltrunas’ jaw was clamped shut. Staff continued attempting CPR for around 15
minutes until ambulance paramedics arrived. It seems clear that attempting CPR
for Mr Baltrunas was inappropriate. We make the following recommendations:
The Governor and Head of Healthcare should ensure that staff are given clear
guidance about the circumstances where resuscitation is and is not
appropriate, in line with national and European guidelines.
The Head of Healthcare should share a copy of this report with Nurse C and
arrange for her clinical supervisor to discuss the Ombudsman’s findings with
her.
Clinical care
98. The clinical reviewer found that Mr Baltrunas’ overall care was of a reasonable
standard and equivalent to that which he would have received in the community.
99. She noted, however, that although he was seen every day by a nurse or doctor
while in the CSU, there were two occasions in July when mental health staff did not
adequately assess his mental state: first on 20 July when there appeared to be a
possible breakdown in communication between the prison GP and Nurse A, and
then on 26 July when another nurse noted that he had been unable to assess Mr
Baltrunas due to the risk he posed and his language limitations. The clinical
reviewer considered that Mr Baltrunas’ mental health care was compromised
through the failure to adequately assess his mental state in the CSU at an early
stage.
Translation
100. There are repeated references to Mr Baltrunas’ poor English. We appreciate that
Mr Baltrunas did not always want to use an official translation service and that staff
started to use the translation service in August when he said that he could not
understand what was being said to him.
101. However, although a nurse said that Mr Baltrunas declined the use of an interpreter
as he spoke enough English to “get by” and staff said that they generally believed
that his understanding and ability to speak English was better than he sometimes
tried to imply, we are concerned that some significant interactions with Mr Baltrunas
took place without any translation assistance. Most notably the segregation reviews
that took place on 10 and 17 July and the mental health assessment that could not
go ahead on 26 July because of ‘language difficulties.
102. We do not consider that it was safe to assume that Mr Baltrunas understood
everything that was being said to him or that he would have been able to discuss
the complexities of his mood and feelings.
103. We recommend:
The Governor and Head of Healthcare should ensure that staff use a
translation service when discussing sensitive or complex matters with
prisoners who do not speak English well
Prisons and Probation Ombudsman 15
Inquest
104. An inquest into Mr Baltrunas’ death concluded that his cause of death was
suspension.
.
16 Prisons and Probation Ombudsman
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