Jonusas, Ricardas

Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Ricardas Jonusas,
a prisoner at HMP Swaleside,
on 16 December 2022
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.
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 Ricardas Jonusas was found hanged in his cell at HMP Swaleside on 16 December
2022. He was 34 years old. I offer my condolences to Mr Jonusas’s family and friends.
Mr Jonusas was the fifth prisoner to take his life at Swaleside in 2022 and the eighth in
three years.
My investigation found that, yet again, suicide and self-harm monitoring (known as ACCT)
was managed poorly. Poor ACCT management was an issue identified in our
investigations into the two self-inflicted deaths that preceded Mr Jonusas’s. HM
Inspectorate of Prisons also highlighted this as an issue following their inspections of
Swaleside in 2021 and 2022.
The prison has told us that a range of work is ongoing to improve ACCT management at
Swaleside. This work needs to deliver sustained improvements if Swaleside is to stop men
at the prison from taking their own lives. I have asked the Executive Director for the Long
Term High Security Estate for assurance that these measures are delivering the
improvements required.
This investigation has again highlighted the detrimental impact that the shortage of staff at
Swaleside is having on the men in its care. Mr Jonusas had no key work sessions due to
lack of staff and was clearly frustrated by spending most of the day locked in his cell,
without purposeful activity. I understand that HMPPS is taking steps to address issues with
staff retention and recruitment at Swaleside. In the meantime, the prison needs to ensure
that it identifies vulnerable prisoners and prioritises support for those most in need.
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 ....................................................................................................................... 7
Findings ......................................................................................................................... 13
Summary
Events
1. On 24 August 2021, Mr Ricardas Jonusas, a Lithuanian national who was serving a
life sentence for murder, was transferred from a prison in Lithuania back to HMP
Wandsworth. On 7 December, he was moved to HMP Swaleside.
2. Between 30 December 2021 and June 2022, staff monitored Mr Jonusas using
suicide and self-harm procedures (known as ACCT) on five occasions. Mr Jonusas
self-harmed numerous times. These incidents were primarily triggered by alcohol
use. Staff made substance misuse referrals, but Mr Jonusas often refused to
engage.
3. On 5 August 2022, while under the influence of alcohol, Mr Jonusas made deep
cuts to his arms using screws taken from the furniture in his cell. He was taken to
hospital but was returned to the prison the same day. Staff started ACCT
procedures four days later. They were unable to explain the delay. Mr Jonusas told
staff he cut himself only when under the influence of drugs or alcohol. He said he
consumed alcohol and drugs because he struggled being locked in a cell on his
own for 22 hours a day. Staff continued ACCT monitoring until 29 August.
4. Staff restarted ACCT monitoring on 14 September, after Mr Jonusas made a deep
cut to his arm using a can lid. He said he wanted a transfer to another prison and a
job. He said he self-harmed to relieve the frustration of being locked up all day and
having no job. He later asked for a move to another wing so he could be with other
Lithuanians, which staff arranged. Staff stopped ACCT monitoring on 22 September
as Mr Jonusas seemed happier and had remained sober.
5. Staff restarted ACCT monitoring on 16 October, after Mr Jonusas told an officer that
he would find him hanging the next day. On the evening of 17 October, staff saw Mr
Jonusas standing on a chair trying to attach a ligature to the light fitting. He told staff
that he was upset that he had been refused a transfer. At a case review on 20
October, he told staff that he planned to end his life that night by cutting his neck.
Staff placed him under constant supervision but stopped it the next day as he
seemed much better and had agreed to engage with the drug and alcohol service.
Staff continued ACCT monitoring until 25 October.
6. From November, Mr Jonusas was employed as a painter on the wing, and he
seemed more settled. There were no suspicions that he was using drugs or alcohol.
7. During a routine check at around 8.45pm on 16 December, an operational support
grade (OSG) noticed that Mr Jonusas had blocked his observation panel. The OSG
looked through a gap and saw a noose. He radioed a medical emergency code.
Staff responded and the control room called for an ambulance. Staff started CPR
and continued until paramedics arrived 30 minutes later. The paramedics assessed
that Mr Jonusas showed clear signs of death and at 9.22pm, they pronounced him
dead.
Prisons and Probation Ombudsman 1
Findings
8. There was no indication that Mr Jonusas’s risk of suicide and self-harm had
increased again at the time of his death.
9. We found that the ACCT procedures put in place in August, September and
October were managed poorly. The case coordinator changed frequently, and
relevant staff were not always invited to case reviews. The care plan was not
completed and there seemed to have been very little consideration given to how to
address Mr Jonusas’s concerns.
10. Poor ACCT management is an issue we have raised with Swaleside numerous
times before. Following our investigations into the two self-inflicted deaths that
preceded Mr Jonusas’s, we were told that work was ongoing to upskill staff on
ACCT procedures, train more staff and quality assure the ACCTs opened. This
work needs to deliver sustained improvements in order to address the issues with
ACCT management at Swaleside.
11. Mr Jonusas had no key work sessions at Swaleside because the prison is not
delivering key work due to staff shortages. While we accept that staff shortages
mean that delivering key work routinely to all prisoners would be very difficult, we
consider that more could be done to prioritise and deliver key work to those most in
need.
12. The clinical reviewer found that the care Mr Jonusas received was of a good
standard and equivalent to that which he could have expected to receive in the
community. She found that appropriate support and referrals were offered and
made to address Mr Jonusas’s substance misuse, but he often refused help.
Recommendations
• The Executive Director for the Long Term High Security Estate should satisfy
himself that the measures introduced to improve ACCT management at Swaleside
have delivered the necessary improvements.
• The Governor should consider prioritising the delivery of key work to specific
vulnerable groups during periods when staffing levels do not allow routine delivery
of key work to all prisoners.
2 Prisons and Probation Ombudsman
The Investigation Process
13. HMPPS notified us of Mr Jonusas’s death on 17 December 2022.
14. The investigator issued notices to staff and prisoners at HMP Swaleside informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Jonusas’s prison and
medical records.
16. The investigator interviewed 14 members of staff at HMP Swaleside between 31
January and 14 March 2023.
17. NHS England commissioned an independent clinical reviewer to review Mr
Jonusas’s clinical care at the prison. The investigator and clinical reviewer jointly
conducted 12 of the interviews.
18. We informed HM Coroner for Kent of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
19. The Ombudsman’s family liaison officer contacted Mr Jonusas’s sister to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not raise any issues but asked for a copy of the report.
20. We shared our initial report with HMPPS. They found no factual inaccuracies.
21. We sent a copy of our report to Mr Jonusas’s sister. She did not notify us of any
factual inaccuracies.
Prisons and Probation Ombudsman 3
Background Information
HMP Swaleside
22. HMP Swaleside, on the Isle of Sheppey, is part of the Long Term High Security
Estate. It holds up to 1,090 men serving sentences of at least four years. Until April
2022, Integrated Care 24 (IC24) provided physical healthcare services at Swaleside
and Oxleas NHS Foundation Trust provided mental healthcare services. From April,
Oxleas has provided both physical and mental healthcare, which includes 24-hour
nursing cover.
HM Inspectorate of Prisons
23. The last full inspection of HMP Swaleside was in October 2021. Inspectors reported
that outcomes for prisoners remained disappointing, particularly in safety and
purposeful activity.
24. Inspectors reported that incidents of self-harm had almost doubled since the last
inspection. They found that the quality of support delivered through assessment,
care in custody and teamwork (ACCT) case management for prisoners at risk of
suicide and self-harm was variable, with some inconsistent case management and
care plans that lacked meaningful or completed actions. In HMIP’s survey, only just
under half of prisoners with experience of being on an ACCT said that they had felt
cared for by staff.
25. Inspectors reported that the delivery of services was hindered by significant
shortages of staff. They reported that having only three quarters of staff available
limited the ability to reinstate purposeful activities for prisoners. Although inspectors
noted that staff shortages were beyond the ability of prison managers to influence
directly, it was nevertheless a fundamental strategic risk and priority, which needed
HMPPS’s intervention and support.
26. HMIP carried out an Independent Review of Progress in July 2022. Inspectors
reported that the shortage of officers had become worse and had led to very limited
time out of cell for most prisoners. No meaningful progress had been made in
addressing staff shortfalls, which meant staffing was now at crisis point and was
having an impact on all aspects of the regime.
27. Incidents of self-harm had declined considerably, though there had been five self-
inflicted deaths since the previous inspection. The standard of ACCT documentation
for prisoners at risk of suicide or self-harm remained poor; reviews were not
multidisciplinary, action plans were inadequate and there were gaps in recorded
observations. However, leaders had recently taken steps to improve the
documentation through additional training and ongoing support from the regional
safety team. Many of the prisoners inspectors spoke to said staff did not have time
to have meaningful conversations with them about their wellbeing, which meant
they still did not always feel well supported.
4 Prisons and Probation Ombudsman
Independent Monitoring Board
28. 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 30 April 2022, the IMB reported
that efforts to implement a worthwhile regime for prisoners had been made difficult
by staff shortages, with just 160 staff available out of an agreed complement of 261.
They found that this was exacerbated by a large proportion of staff having less than
two years’ experience.
29. The IMB reported that the almost total withdrawal of the key worker scheme due to
staff shortages had led to further frustration and worry for prisoners and may have
been a factor in the recent increase in deaths at the prison. The IMB also reported
that although staffing of the safer custody team had increased, cross-deployment to
other areas meant that they had not been able to provide as much support to
prisoners as they would have liked.
Previous deaths at HMP Swaleside
30. Mr Jonusas was the 21st prisoner to die at Swaleside since December 2019. Of the
previous deaths, seven were self-inflicted, two were drug related and 11 were from
natural causes. There were five self-inflicted deaths during 2022 and there has
been a further self-inflicted death in 2023. Due to the high incidence of self-inflicted
deaths at Swaleside, HMPPS headquarters has been providing additional
monitoring and support.
31. We have previously made numerous recommendations to Swaleside about ACCT
management, in particular about properly assessing risk and creating appropriate
care plans. Following our investigations into the two self-inflicted deaths before Mr
Jonusas’s, which occurred in June and September 2022, we were told that the
prison had been working closely with the regional and group safety teams to upskill
staff on ACCT procedures. This included training sessions and floor walking
exercises with a focus on identifying risks and triggers for suicide and self-harm and
completing the care plan. A quality assurance process was in place to ensure that
ACCT was being delivered in line with expectations, including checking that
appropriate staff were invited to case reviews. Additional training had been
scheduled to increase the number of ACCT trained staff.
32. We also recently made recommendations about key work and about staffing levels.
We were told that Swaleside recognised the importance of key work but that staff
shortages meant that key work could not be delivered in line with expectations.
Recruitment remained ongoing and there had been improvements made to pay and
benefits with a view to attracting and retaining more staff at Swaleside. We were
also told that in October 2022, the Standards Coaching Team started their
deployment to Swaleside. Their aim was to promote consistent best practice across
routine tasks, show how to create positive staff-prisoner relationships, encourage
the use of Five-Minute Interventions and build confidence in staff with less
experience.
Prisons and Probation Ombudsman 5
Assessment, Care in Custody and Teamwork
33. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and 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.
Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011. 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 multidisciplinary review meetings involving the prisoner.
34. As part of the process, a care plan (plan of care, support and intervention) is put in
place. The ACCT should not be closed until all the actions on the care plan have
been completed. All decisions made as part of the ACCT process and any relevant
observations about the prisoner should be written in the ACCT booklet, which
accompanies the prisoner as they move around the prison.
6 Prisons and Probation Ombudsman
Key Events
35. On 20 October 2020, Mr Ricardas Jonusas, a Lithuanian national, was sentenced to
life imprisonment for murder. He spent time at HMP Forest Bank and HMP
Wandsworth before being repatriated back to a Lithuanian prison in January 2021.
On 24 August, Mr Jonusas was returned to Wandsworth. (We have not been able to
establish the reason for his return to the UK.) While he had some family in the UK,
his wife and son were in Lithuania.
36. On 7 December, Mr Jonusas was moved to HMP Swaleside. Between 30
December and April 2022, staff supported Mr Jonusas using suicide and self-harm
prevention procedures (known as ACCT) five times. During this time, Mr Jonusas
had numerous incidents of self-harm which were primarily triggered by alcohol use.
While under the influence of alcohol, Mr Jonusas frequently became threatening
and violent towards staff. Staff made substance misuse referrals on each occasion
when alcohol was involved, but Mr Jonusas did not engage.
37. On 29 June, Mr Jonusas, while under the influence, became violent towards staff
when they asked him to return to his cell. Staff restrained Mr Jonusas and he bit an
officer when they were trying to get him into his cell.
38. Around 30 minutes later, a supervising officer (SO) and healthcare staff checked on
Mr Jonusas. They saw he was lying on the floor, so the SO and other officers
entered the cell. When they got close enough to check Mr Jonusas, he tried to
attack them. Later in the day, Mr Jonusas pressed his emergency cell bell and
asked to see healthcare staff as he said he had been injured during the earlier
restraint. Healthcare staff did not want to enter the cell due to Mr Jonusas’s earlier
behaviour. Mr Jonusas became aggressive and threatened to kill an officer.
39. On 1 July, Mr Jonusas was downgraded to the basic regime. This meant that he
had certain privileges removed, such as access to a TV, and his permitted spending
on canteen (items from the prison shop) was reduced.
40. On 11 July, Swaleside refused Mr Jonusas’s request to be moved to HMP
Doncaster to be closer to his family as Doncaster is a local prison (not intended to
hold prisoners serving long sentences) and therefore he did not meet the criteria.
41. On 21 July, staff conducted a suspicion-led search of Mr Jonusas’s cell and found
two litres of fermenting liquid (illegally brewed alcohol).
42. On 5 August, an officer checked on Mr Jonusas in his cell and saw that he was
cutting his arms with screws taken out of furniture in his cell. The officer called a
code red (a medical emergency code indicating severe blood loss) and was joined
by two other officers. They entered the cell and restrained Mr Jonusas, to prevent
him from self-harming further. Mr Jonusas was taken for treatment in hospital and
returned the same day.
ACCT – 9 to 29 August
43. On 9 August, an officer started ACCT procedures (in response to the incident on 5
August).
Prisons and Probation Ombudsman 7
44. That afternoon, an officer held the ACCT assessment interview. He noted that Mr
Jonusas was initially reluctant to engage and said he did not want to be on an
ACCT. He told the officer that he only cut himself when he was under the influence
of drugs or alcohol, that he did this to relieve stress and that he had no intention of
ending his life. When the officer asked him why he took drugs, he said, ‘Imagine
being locked in cell all day, staring at same for [sic] walls, all day for 22 hours a day
and see if you don’t want to get high’. He asked for a job to keep himself busy.
45. On 10 August, a SO tried to hold the first ACCT case review. A mental health
worker and substance misuse worker attended. However, Mr Jonusas failed to
attend as he was under the influence of an illicit substance. It was agreed that the
case review should not go ahead as Mr Jonusas was too incoherent to participate.
46. The SO held the ACCT review the next day. A member of wing staff attended. The
SO noted that no outside agencies were available but that she would get them to
see Mr Jonusas another time. Mr Jonusas said he was struggling with ‘all the lock
up’ as he had shared a cell before. (He was in a single cell on G Wing.) He said he
was smoking drugs a lot more and getting into debt. He said he knew he needed
help and would like a move further north to be nearer his family as they would help
settle him down. He asked for a move to C Wing as he knew people on there who
could support him. The SO noted that she would see if he was eligible for a move
(but there is no evidence that she followed this up).
47. On 13 August, a SO and an officer went to Mr Jonusas’s cell to conduct a cell
search. The SO asked Mr Jonusas if he had anything in his cell that should not be
there, and he pointed to underneath his bed and said it was not his. The SO found
around 20 litres of fermenting liquid under the bed.
48. On 16 August, a SO held an ACCT review. A drug and alcohol recovery worker
from Change, Grow, Live (CGL) attended, along with another SO. Mr Jonusas said
he was okay but worried about paying back money he owed. The CGL worker gave
him paperwork to sign, but Mr Jonusas refused to as he said he had lost faith in
their service as they gave him no help last time when he had asked for it. He asked
again for a transfer to Doncaster as he had family there.
49. On 29 August, a custodial manager (CM) chaired an ACCT review. A SO attended,
and a member of healthcare staff contributed by telephone. The case review log
noted that there had been no incidents of self-harm for three weeks. Mr Jonusas
said he had only self-harmed that day due to alcohol and that while he was
continuing to use alcohol, he did so rarely and drank less when he did. The SO
noted that Mr Jonusas was well known to him and that he was unlikely to self-harm
again for a while. He noted that Mr Jonusas needed to work with the drug and
alcohol service to address his drinking. The case review team agreed that an ACCT
was no longer appropriate and should be closed.
50. The same day, staff upgraded Mr Jonusas to standard IEP.
September
51. On 11 September, an officer saw Mr Jonusas being helped back to his cell by three
other prisoners as he was heavily under the influence. He noted that when Mr
Jonusas got back into his cell, he pulled what appeared to be an improvised
8 Prisons and Probation Ombudsman
weapon from his trousers, laughed and then hid it. He asked the three prisoners to
leave and locked Mr Jonusas in his cell.
52. On 13 September, staff carried out a cell search. They did not find a weapon but
found an improvised distilling kit underneath the bed.
ACCT – 14 to 22 September
53. On 14 September, staff called a code red after Mr Jonusas made a deep cut to his
arm using a can lid. Mr Jonusas said it was because he wanted a transfer to
another prison, and he wanted a job. Officers verbally de-escalated the situation,
and Mr Jonusas handed over the can lid. He refused to be treated by healthcare
staff, although they remained by him while he cleaned the wound. Healthcare staff
recorded that they ensured the wound had stopped bleeding before they left. Staff
reopened the ACCT and referred Mr Jonusas to the drug and alcohol service.
54. A SO chaired an ACCT review on 15 September. A wing officer attended. A CGL
worker was invited but said that Mr Jonusas no longer engaged with them. Mr
Jonusas said that he had self-harmed due to frustration with being locked up and
having no job. He also said he wanted a move to C Wing so he could be with other
Lithuanians and have more peace and quiet. A CM arranged a move to C Wing
later that day. He noted that Mr Jonusas was happy about the move.
55. On 19 September, a SO checked on Mr Jonusas after a death at Swaleside. She
noted that Mr Jonusas was in a good mood and was happy he was on C Wing. He
showed her a letter from his solicitor that had been sent to the Governor asking for
a move to Doncaster. She said that she would chase it up.
56. On 22 September, a SO chaired an ACCT review. Another SO and other wing staff
attended. He noted that Mr Jonusas was happy with his new location and had peer
support. Mr Jonusas had been sober since moving wing, and staff were assisting
him in finding employment, although they explained that opportunities were limited,
and he needed to be patient. The case review team agreed to close the ACCT.
ACCT – 16 to 25 October
57. On 16 October, an officer restarted ACCT procedures for Mr Jonusas. He noted
that Mr Jonusas had put out his hand for him to shake and said, ‘It has been good
knowing you but tomorrow you’ll find me hanging’. He noted that Mr Jonusas
seemed serious and was distressed when going back into his cell. He was
concerned as Mr Jonusas was normally in a good mood with him.
58. A SO tried to hold an ACCT review the next day but Mr Jonusas said he would not
engage until he got a move out of Swaleside. She noted that she would reschedule
the review and speak with him that afternoon or the next day to encourage him to
attend.
59. On the evening of 17 October, during a routine check, an officer saw Mr Jonusas
standing on a chair in his cell trying to tie a ligature to the light fitting. When he
asked him what he was doing, Mr Jonusas swore at him. The officer tried to speak
with him, but Mr Jonusas put the ligature around his neck and stepped off the chair.
Prisons and Probation Ombudsman 9
The ligature snapped straight away, and the officer called for night support staff to
attend. The officer increased the level of observations to every 30 minutes.
60. On 18 October, a SO held an ACCT review. Mr Jonusas was upset that he had
been turned down for a transfer due to being on basic. He said that he had been on
standard when he was told and was then moved to basic the next day. He said
people were lying to him and also that he did not know who his offender manager
was as they had never been to see him. The SO said he would invite them to the
next ACCT review so these issues could be discussed in person (but there is no
evidence that he did, and the OM did not attend the next ACCT review). (We found
no information about Mr Jonusas being refused a transfer at around this time.)
61. On 20 October, a SO held an ACCT review. He noted that Mr Jonusas asked if any
progress had been made in transferring him to Doncaster or Manchester. At
interview, the SO said that he had told Mr Jonusas that a transfer was not an
immediate process and he needed to be patient. The SO noted that Mr Jonusas
stated that he planned to end his life that night by cutting his neck. He said he had
made preparations to end it all and had told his partner to find another man. The
case review team agreed that Mr Jonusas should be placed under constant
supervision and moved him to a constant supervision cell on the healthcare unit.
62. On 21 October, a CM held an ACCT review which was attended by healthcare staff
and the substance misuse service. She noted that Mr Jonusas’s issue was not
seeing his family. They were coming to the UK and staying in Manchester, and he
was desperate to see them. He said he would engage with the drug and alcohol
service. The case review team agreed that constant supervision was no longer
necessary as Mr Jonusas’s presentation was better than the previous day. They
reduced observations to hourly and moved Mr Jonusas back to C Wing.
63. On 25 October, a CM held an ACCT review. She noted that Mr Jonusas understood
that she was awaiting information from the Offender Management Unit (OMU). She
said that she was going to ask Mr Jonusas to paint the landing and that he would
get a bonus payment if his current behaviour continued. The case review team
agreed to close the ACCT. She said there were many positive factors in place
which made staff consider that Mr Jonusas’s risk of suicide and self-harm was
significantly reduced. She said she did not have input from healthcare staff when
the ACCT was closed but discussed Mr Jonusas at length with the substance
misuse service.
November/December
64. On 6 November, an officer recorded in Mr Jonusas’s prison record that he had been
decorating the wing and had made a very good job of it. They noted that he was
always willing to help on the wing and was a great asset. This was the last entry in
Mr Jonusas’s prison record.
65. Several members of staff told us that Mr Jonusas had a period of stability while he
was working as a wing painter, and he did not appear to be using alcohol during this
time. Staff said as they were aware alcohol was a key trigger and as he was sober
in this time, they did not consider him to be at increased risk of suicide or self-harm.
10 Prisons and Probation Ombudsman
Events of 16 December
66. At around 8.40pm, during a routine check, an Operational Support Grade (OSG)
found that Mr Jonusas’s observation panel was covered. He tried to get a response
from Mr Jonusas but there was no answer. He asked for staff assistance over the
radio. The OSG then managed to look through a gap and saw a noose, so called a
code blue (a medical emergency code used when a prisoner is unconscious or
having breathing difficulties). The control room log shows an ambulance was called
at 8.45pm.
67. Staff arrived at the cell five minutes after the OSG first checked the cell. They
looked in, and a CM immediately got his keys out as an officer took her anti-ligature
knife out. Another officer said during interview that they opened the cell and drew
back the privacy curtain Mr Jonusas had used to block the view and found him
suspended.
68. The CM took hold of Mr Jonusas’ legs to support him, while two officers cut the
ligature. The CM then cut the ligature from around his neck. One officer said during
interview that she noticed significant damage to Mr Jonusas’s neck when they
removed the ligature. Two more officers also responded to the code blue.
69. A nurse responded to the code blue and arrived as officers were cutting Mr Jonusas
down. He advised them to move him to the landing where there was more space to
work on him. He noted that Mr Jonusas was unresponsive, but CPR and oxygen
was given as emergency first aid. The nurse said he could clearly smell alcohol on
Mr Jonusas, and vomit was being removed from his airways as they were giving
first aid.
70. Staff attempted to use a defibrillator but could not find the pads on the one they had
on the wing, so an officer went to the nearest wing to get another. A working
defibrillator was attached shortly after, and staff followed the instructions.
71. Paramedics arrived at the cell around 9.20pm. The ambulance crew noted
hypostasis (the pooling of blood or fluid in the lower limbs) was present in Mr
Jonusas, which they considered to be a sign of death. He was pronounced dead at
9.22pm.
Contact with Mr Jonusas’s family
72. The prison appointed a family liaison officer (FLO)on 16 December. Staff could not
identify the next of kin from prison documents. The following day, staff tried to
contact the Lithuanian Embassy to get contact information, as well as Mr Jonusas’s
solicitor.
73. On 19 December, the FLO contacted Mr Jonusas’s sister, after obtaining her
information. He offered condolences and financial assistance for the funeral.
Prisons and Probation Ombudsman 11
Support for prisoners and staff
74. After Mr Jonusas’s death, a prison manager 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.
75. The prison posted notices informing other prisoners of Mr Jonusas’s 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 Jonusas’s death.
Post-mortem report
76. The post-mortem examination found that Mr Jonusas died from hanging. Toxicology
tests showed the presence of alcohol at three times the legal driving limit.
12 Prisons and Probation Ombudsman
Findings
Managing Mr Jonusas’s risk of suicide and self-harm
77. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures (known
as ACCT) that staff must follow if they identify that a prisoner is at risk of suicide or
self-harm.
78. Mr Jonusas was monitored using ACCT on three occasions in the months leading
up to his death, in August, September and October 2022. Staff stopped ACCT
monitoring on 25 October and Mr Jonusas then had a fairly settled period over the
next seven weeks. There was no indication that his risk had increased again when
he was found hanged on 16 December.
79. However, we consider that there were various issues with the ACCT management
between August and October.
80. The prison was unable to explain why staff failed to start ACCT procedures after Mr
Jonusas self-harmed on 5 August. He returned from hospital the same day and yet
staff did not start ACCT monitoring until 9 August.
81. There was not a consistent ACCT case coordinator for any of the ACCTs. There
were eight ACCT case coordinators across the three periods, with four in October
alone. This is poor practice as there was a lack of continuity between ACCT
reviews.
82. The first case review on 10 August did not go ahead and was rescheduled for the
next day. Only one SO, the case coordinator, and a member of wing staff attended.
The SO recorded that ‘no outside agencies were available’. It is unclear whether
anyone from healthcare was invited as they should have been or asked to provide
input. Although a drug and alcohol recovery worker attended the next review on 16
August, again there was no one from the mental health team and no evidence that
they were invited or asked for input.
83. During the ACCT in September, only wing staff attended the ACCT reviews with no
input from either mental health staff or substance misuse staff. (A member of CGL
staff was invited to the first review but said that Mr Jonusas no longer engaged with
them.) When interviewed, the Head of Healthcare said that it was often challenging
for healthcare staff to attend ACCT reviews due to short staffing and clashes with
clinical tasks (such as medication rounds) but that they always tried to provide
input, either written or by telephone if invited. She said there was work ongoing to
try to arrange ACCT reviews at times that would maximise healthcare attendance.
She added that healthcare staff had limited interactions with Mr Jonusas due to his
refusal to engage.
84. During the ACCT in October, Mr Jonusas asked to see his offender manager and
the case coordinator said they would be invited to the next review. There is no
evidence that they were. Subsequently the ACCT was closed without Mr Jonusas
having seen anyone from OMU. The case coordinator noted that she was awaiting
an update from OMU but still closed the ACCT.
Prisons and Probation Ombudsman 13
85. PSI 64/2011 says that the case review team must complete the care plan at the first
case review, with actions aimed at reducing the risk of suicide and self-harm, which
reflect the prisoner’s needs. Only the first part of Mr Jonusas’s care plan, setting out
his risks and triggers, was completed. The rest of the plan was left blank and there
were no support actions listed.
86. We consider that there were various issues that should have been on the care plan.
One of Mr Jonusas’s main issues was his desire for a transfer to a prison in the
Northwest of England to be nearer his family. While we understand that this might
not have been possible, and certainly not straightaway, there should have been an
action to look into this and updates/decisions should have been communicated and
explained to Mr Jonusas during the case reviews.
87. Mr Jonusas repeatedly said he found it very difficult being locked in a cell on his
own for 22 hours a day, when he had previously had a cellmate. We cannot see any
evidence from the ACCT paperwork that consideration was given to moving him to
a shared cell, which would have provided a protective factor. He also said that he
struggled with not having a job. Again, there was little evidence in the ACCT
paperwork that this was looked into. (We note that Mr Jonusas was eventually given
a job as a wing painter, which appeared to have a very positive impact on him.)
88. There was a cluster of five self-inflicted deaths at Swaleside in 2022, of which Mr
Jonusas’s was the last that year. (There has been another one since, in 2023.) Our
investigations into the two self-inflicted deaths that preceded Mr Jonusas’s, which
occurred in June and September 2022, identified similar issues with the poor quality
of ACCT management. We were told that work was ongoing to upskill staff on
ACCT procedures, increase the number of ACCT trained staff and quality assure
ACCTs to ensure that they were being delivered in line with expectations.
89. This work needs to deliver sustained improvement in the management of ACCT at
Swaleside. We recommend:
The Executive Director for the Long Term High Security Estate should satisfy
himself that the measures introduced to improve ACCT management at
Swaleside has delivered the necessary improvements.
Key work
90. The Prison Service’s Manage the Custodial Sentence Policy Framework 2018 says
that all prisoners within the male closed estate must be allocated to a prison officer
who will have a key worker role. It also says that Governors must ensure that time
is made available for an average of 45 minutes per prisoner per week for the
delivery of key work, which should include time with each prisoner.
91. Mr Jonusas did not receive any key worker sessions during his time at Swaleside.
Key worker sessions are not currently being carried out at Swaleside due to staff
shortages. In their latest annual report, published around a month after Mr
Jonusas’s death, the IMB reported that Swaleside was operating with 160 staff in
place out of a total of 261 posts. HMIP also highlighted the issue of staffing in their
most recent report, and this trend appears to have been continuing. During our
investigation, it became apparent that these shortages had a significant impact on
14 Prisons and Probation Ombudsman
staff’s ability to deliver a full regime and to complete daily tasks to the expected
standard.
92. In response to previous recommendations on key work and staffing, we were told
that Swaleside recognised the importance of key work but that staff shortages
meant that key work could not be delivered in line with expectations. In the interim,
staff were encouraged to engage positively with prisoners whenever possible and to
ensure that relevant concerns were either addressed or escalated as soon as
discovered.
93. HMPPS told us that recruitment remained ongoing and there had been
improvements made to pay and benefits with a view to attracting and retaining more
staff at Swaleside. They said that once staffing levels allowed, key work would be
reintroduced. They said that prisoners being supported using ACCT were provided
with additional support.
94. We were also told that in October 2022, the Standards Coaching Team started their
deployment to Swaleside. Their aim was to promote consistent best practice across
routine tasks, show how to create positive staff-prisoner relationships, encourage
the use of Five-Minute Interventions and build confidence in staff with less
experience.
95. Mr Jonusas frequently attempted suicide and self-harmed and was supported using
ACCT multiple times at Swaleside. While we accept that the staffing levels at
Swaleside make it very difficult to deliver key work routinely to all prisoners, we
consider that more could be done to prioritise key work for those most in need. We
recommend:
The Governor should consider prioritising the delivery of key work to specific
vulnerable groups during periods when staffing levels do not allow routine
delivery of key work to all prisoners.
Clinical care
96. The clinical reviewer found that the care Mr Jonusas received was of a good
standard and equivalent to that which he could have expected to receive in the
community.
97. She noted that appropriate support and referrals were offered and made to address
Mr Jonusas’s substance misuse and alcohol dependence, but his engagement was
variable and he often declined help.
98. Mr Jonusas was not diagnosed with any mental health conditions so was not
prescribed any mental health medication. The clinical reviewer was satisfied that he
received appropriate support from mental health staff for his self-harming.
Inquest
99. The inquest, held from 2 to 5 April 2024, concluded that Mr Jonusas died by
suicide.
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