Damian Bugno-Swierz

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Independent investigation
into the death of
Mr Damian Bugno-Swierz,
a prisoner at HMP Wandsworth,
on 7 November 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, 2025
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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 Damian Bugno-Swierz was found hanging in his cell at HMP Wandsworth on 7
November 2023. Staff and paramedics tried to resuscitate him but were unsuccessful. Mr
Bugno-Swierz was 29 years old. I offer my condolences to his family and friends.
Mr Bugno-Swierz was the fifteenth prisoner to take his own life at Wandsworth in three
years. Up to the end of March 2024, there were two further self-inflicted deaths.
Mr Bugno-Swierz had no history of self-harm and gave no indication to staff or fellow
prisoners that he was at risk of suicide or self-harm in the lead up to his death. Mr Bugno-
Swierz, along with two friends, was caught drinking hooch (illegally brewed alcohol) on the
day he died. All three of them were later found with ligatures around their necks but only
Mr Bugno-Swierz died.
It appears that the hooch was the trigger for Mr Bugno-Swierz’s actions. Wandsworth has
an ongoing problem with hooch, however, I am satisfied that the prison has employed
good strategies and practices to try to tackle this problem.
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 September 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 8 April 2021, Mr Damian Bugno-Swierz, a Polish national, was remanded in
prison, charged with grievous bodily harm (GBH). On 1 December, he was
sentenced to four years and three months in prison. In the meantime, he had
attended court and been remanded in custody for separate violent offences and for
an extradition case relating to drugs.
2. On 13 July 2023, Mr Bugno-Swierz was moved to HMP Wandsworth.
3. On 7 November, at around 5.00pm, staff discovered that Mr Bugno-Swierz and two
friends (his cellmate and another prisoner who had been locked into the cell in
error) were drinking illicitly brewed alcohol (‘hooch’) in Mr Bugno-Swierz’s cell. They
had also damaged the cell. Staff removed Mr Bugno-Swierz and placed him in a
separate cell.
4. At 6.18pm, staff took Mr Bugno-Swierz to the Care and Separation Unit (CSU – the
segregation unit) for damaging his cell and being under the influence of alcohol.
5. Shortly before 8.00pm, Mr Bugno-Swierz’s two friends joined him in the CSU. Staff
escorted them under restraint as they were both non-compliant and under the
influence of illicit substances.
6. Within an hour of Mr Bugno-Swierz’s friends arriving in the CSU, staff found both
with ligatures tied around their necks. They started suicide and self-harm monitoring
(known as ACCT).
7. At 11.01pm, an officer went to check on Mr Bugno-Swierz but could not see him
through the cell’s observation panel. He switched on the cell's emergency light, but
it was not working properly. The officer went to get support from other staff.
8. Two officers went to the cell at 11.03pm, looked through the observation panel and
then walked away. One of the officers returned a few minutes later and again
looked through the observation panel and walked away.
9. At 11.07pm, a supervising officer (SO) arrived at the cell and entered with two
officers. They found Mr Bugno-Swierz behind his cell door with a ligature around his
neck. They removed the ligature and started CPR. The SO radioed a medical
emergency code and the control room called for an ambulance. Healthcare staff
arrived and continued CPR.
10. Ambulance paramedics arrived at 11.20pm and took over CPR. They were unable
to resuscitate Mr Bugno-Swierz and at 11.59pm, they pronounced that he was
dead.
11. Toxicology tests showed the presence of alcohol at twice the level of the legal
driving limit. No drugs were found.
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Findings
12. Mr Bugno-Swierz gave no indication to staff that he was at risk of suicide or self-
harm in the lead up to his death. We are satisfied that staff could not have foreseen
his actions.
13. Mr Bugno-Swierz consumed alcohol before he died. Although the hooch problem at
Wandsworth is significant and complex, we are satisfied that the prison has
employed good strategies and practices to try to manage this problem.
14. We make no recommendations.
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The Investigation Process
15. HMPPS notified us of Mr Bugno-Swierz’s death on 8 November 2023.
16. The investigator issued notices to staff and prisoners at HMP Wandsworth
informing them of the investigation and asking anyone with relevant information to
contact him. Two prisoners contacted the investigator as a result.
17. The investigator visited Wandsworth on 13 November 2023 and 4 March 2024. He
obtained copies of relevant extracts from Mr Bugno-Swierz’s prison and medical
records, CCTV and body worn video camera (BWVC) footage and a recording of
radio transmissions. He also obtained the HMPPS Early Learning Review, and
Ambulance Service records.
18. The investigator interviewed one member of staff and the two prisoners who had
contacted him at Wandsworth on 13 November 2023 and 4 March 2024. He
conducted interviews with a further five members of staff on 20 and 27 March by
video call.
19. The investigator obtained further information from the Head of Safety, Head of Drug
strategy, Head of Residence, Head of Reducing Reoffending, and the Deputy Head
of Security.
20. NHS England commissioned an independent clinical reviewer to review Mr Bugno-
Swierz’s clinical care at the prison. The investigator and clinical reviewer conducted
joint interviews with three members of healthcare staff on 2 February by video call.
21. We informed HM Coroner for London Inner West of the investigation. The Coroner
gave us the results of the toxicology tests. We have sent the Coroner a copy of this
report.
22. We shared our initial report with HMPPS. They pointed out a factual inaccuracy
which has been amended in this report.
23. We sent a copy of our initial report to Mr Bugno-Swierz’s partner and their solicitor.
Mr Bugno-Swierz’s partner pointed out some factual inaccuracies which have been
amended in the report. Mr Bugno-Swierz’s partner raised some other concerns
which have been addressed in a separate letter.
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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.
25. As a result of the number of self-inflicted deaths, Wandsworth is receiving support
and monitoring from HMPPS headquarters.
HM Inspectorate of Prisons
26. The most recent full inspection of Wandsworth was in September 2021. Inspectors
reported that the prison faced many challenges, including staff shortages and
deteriorating buildings. Nearly half of the prisoners at Wandsworth were foreign
nationals, many of whom came from eastern Europe. The inspectors found the
prison, the education service and, in particular, Home Office staff, were not doing
enough to support this group of prisoners.
27. Inspectors found that there was a good strategic approach to tackling drug supply.
There had been some improvements to physical security measures, and mandatory
drug testing had begun, but more staff training was needed in key areas, such as
the gatehouse and the post room, to provide a consistent approach.
28. Inspectors noted that there had been nine self-inflicted deaths and two deaths
linked to drug misuse since the previous inspection in 2018. The prison had acted
swiftly in response to the recommendations from the Prisons and Probation
Ombudsman (PPO) investigation reports received to date. However, inspectors
found there was no published overall safety strategy and supporting action plan to
make the prison safer.
Independent Monitoring Board
29. 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.
Previous deaths at HMP Wandsworth
30. Mr Bugno-Swierz was the twentieth prisoner to die at Wandsworth since November
2020. Of the previous deaths, 14 were self-inflicted, three were from natural causes,
one was drug related, and in the other, the cause of death was unascertained. Up
to the end of March 2024, there were two further self-inflicted deaths.
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Key worker scheme
31. 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. This says:
• All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
• Key workers must have completed the required training.
• Governors in the male closed estate must ensure that time is made available
for an average of 45 minutes per prisoner per week for delivery of the key
worker role, which includes individual time with each prisoner.
32. Within this allocated time, key workers can vary individual sessions to provide a
responsive service, reflecting individual need and stage in the sentence. A key
worker session can consist of a structured interview or a range of activities such as
attending an ACCT review, meeting family during a visit or engaging in conversation
during an activity to build relationships.
33. 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
34. On 8 April 2021, Mr Damian Bugno-Swierz was remanded in prison, charged with
grievous bodily harm (GBH), and sent to HMP Lincoln. It was not his first time in
prison. He moved prisons several times due to court appearances.
35. In November, Mr Bugno-Swierz appeared in court in connection with an extradition
case related to drugs and in connection with further violent offences. He was
remanded in custody.
36. On 1 December, Mr Bugno-Swierz was sentenced to four years and three months
for GBH. Although he was due to be released from prison on 23 May 2023 for this
sentence, he continued to be remanded for alleged further violent offences and the
extradition case.
37. Mr Bugno-Swierz was a Polish national. He had positive relationships with prison
staff and other prisoners and engaged with work and education. However, there
was information to suggest that Mr Bugno-Swierz participated in the illicit drug trade
in prison.
38. In February 2022, while at HMP Pentonville, Mr Bugno-Swierz was caught with a
mobile phone and charger. In October 2022, he was identified as being part of an
Organised Crime Group (OCG).
39. On 22 November, prison staff noted that Mr Bugno-Swierz was told by his partner
that his brother had been murdered in Poland.
40. On 13 July 2023, Mr Bugno-Swierz was sent to HMP Wandsworth.
41. He told reception staff that he had no history of substance misuse. (Mr Bugno-
Swierz had a history of cocaine and alcohol use and completed alcohol and drugs
courses at Lincoln.) Mr Bugno-Swierz had no known history of attempted suicide or
self-harm.
42. On 1 November, an officer noted that an intelligence led search was conducted on
the cell of Mr Bugno-Swierz and his cellmate. Prison staff found an iPhone and
charger, improvised tools, and alcohol brewing equipment. Mr Bugno-Swierz and
his cellmate were both placed on report (a disciplinary charge).
Events of 7 November
43. On 7 November, Mr Bugno-Swierz spoke to his partner twice. They spoke for
around five minutes. (The investigator was unable to listen to the call as
Wandsworth could not provide the recording as, despite requests to provide it, they
had deleted it from their system.) Mr Bugno-Swierz’s partner told us that Mr Bugno-
Swierz was cheerful. She said they talked about the renovation of their home, and
about their son.
44. At evening lock up, at around 5.00pm, another prisoner was mistakenly locked into
the cell Mr Bugno-Swierz shared with his cellmate. The prisoner told the
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investigator that the three of them were having a party with hooch supplied by Mr
Bugno-Swierz.
45. Shortly afterwards, staff realised that there were three people in the cell. They also
noted that the cell had been damaged. They then mistakenly removed Mr Bugno-
Swierz and placed him in a separate cell.
46. At 6.18pm, staff took Mr Bugno-Swierz to the Care and Separation Unit (CSU – the
segregation unit). Body Worn Video Camera (BWVC) footage shows that Mr
Bugno-Swierz was in handcuffs but walked compliantly to the CSU. At times he
appeared slightly unsteady on his feet. (Mr Bugno-Swierz was taken to the CSU for
being under the influence and for damaging his cell, both of which are breaches of
prison rules.)
47. Staff searched Mr Bugno-Swierz when he arrived at the CSU. A nurse saw Mr
Bugno-Swierz as he left the searching cell. She assessed that Mr Bugno-Swierz
was fit to be held in the CSU. She noted that he was coherent, swaying a little on
his feet and there was no aggression or hostility from him.
48. At 6.23pm, staff took Mr Bugno-Swierz to a CSU cell. At 6.37pm, Mr Bugno-Swierz
activated his emergency cell bell (ECB). CCTV footage shows that at 6.45pm, an
officer went to Mr Bugno-Swierz’s cell and spoke with him for around 40 seconds.
49. At 6.49pm, Mr Bungo-Swierz again activated his ECB. CCTV footage shows that at
7.01pm, the officer went to Mr Bugno-Swierz’s cell and appeared to speak with him
again.
50. At 7.10pm, Mr Bugno-Swierz activated his ECB again. CCTV footage shows that
the officer responded at 7.24pm and appeared to speak to Mr Bugno-Swierz. The
officer told the investigator that Mr Bugno-Swierz asked him how long he would be
in the CSU. He said he told Mr Bugno-Swierz that he was on Rule 53, which meant
that he could be held in segregation from the time he was charged with an alleged
offence to the adjudication hearing. He said Mr Bugno-Swierz was calm during their
interactions.
51. Meanwhile, at around 7.20pm, staff removed two prisoners from Mr Bugno-Swierz’s
original cell after they had further damaged and flooded the cell. They escorted both
prisoners under restraint to the CSU. BWVC and Video Camera (VC) footage
shows that both prisoners were non-compliant during the move and appeared to be
under the influence of illicit substances. One prisoner arrived in the CSU at 7.51pm
and the other arrived at 7.59pm.
52. At 8.19pm, Mr Bugno-Swierz activated his ECB again.
53. CCTV footage shows that staff escorted Prisoner A past Mr Bugno-Swierz’s cell at
8.20pm.
54. CCTV footage shows that at 8.26 pm, two officers went to Mr Bugno-Swierz’s cell.
They opened his observation panel for a moment and then turned off the ECB
activation light outside the cell. One officer told the investigator that when he
opened the observation panel, Mr Bugno-Swierz shouted at him aggressively. He
said that as Mr Bugno-Swierz was intoxicated, he thought that talking to him would
further antagonise him.
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55. At 8.27pm, Mr Bugno-Swierz activated his ECB again.
56. At around 8.37pm, staff found Prisoner A with a ligature around his neck. They
removed the ligature, called an ambulance and administered oxygen. He had
recovered by the time paramedics arrived. Staff started suicide and self-harm
monitoring (known as ACCT).
57. At 8.38pm, an officer went to Mr Bugno-Swierz’s cell, turned off the ECB activation
light and looked through the observation panel for around ten seconds. He told the
investigator Mr Bugno-Swierz was standing in the middle of the cell and did not
respond when he tried to talk to him.
58. At around 8.45pm, staff found Prisoner B with a ligature around his neck. He
appeared intoxicated but was responsive. Staff removed the ligature and restarted
ACCT procedures (staff had stopped ACCT monitoring for Prisoner B a week
before).
59. At 9.20pm, an officer went to Mr Bugno-Swierz’s cell and looked into the cell for
around 13 seconds. He told the investigator that he saw Mr Bugno-Swierz lying on
his bed.
60. At 9.45pm, an officer went to Mr Bugno-Swierz’s cell and looked through the
observation panel.
61. At 9.59pm, an officer returned to Mr Bugno-Swierz’s cell and looked through the
observation panel for around five seconds. He told the investigator that he saw Mr
Bugno-Swierz lying on his bed.
62. In the CSU prisoners are subject to standard hourly checks unless more frequent
checks are directed. Mr Bugno-Swierz was checked at least hourly for most of the
evening. At 11.01pm, Officer A went to Mr Bugno-Swierz’s cell, looked through the
observation panel and turned on the emergency light (which was not working
properly as it was flickering). He told the investigator he could not see Mr Bugno-
Swierz. He said his radio had run out of battery, so he asked two other officers to
check the cell while he went to speak with a Supervising Officer (SO) (Oscar 2 – the
second most senior officer in charge at night) to explain the situation and change
his radio battery.
63. At 11.03pm, both officers went to Mr Bugno-Swierz’s cell. Officer C looked through
the observation panel. Both officers then left. In interview, Officer C said that he
switched on the emergency light but that it was flickering so he could not see clearly
into the cell (officers are unable to turn on the main cell light from outside the cell).
He said he then went to find a torch but was unsuccessful.
64. At 11.06pm, Officer C returned to Mr Bugno-Swierz’s cell, looked through the
observation panel briefly and then walked away.
65. At 11.07pm, the SO, Officer A and Officer C arrived at the cell. After looking through
the observation panel they entered. Officer A told the investigator that as they
entered, he saw that Mr Bugno-Swierz was behind and to the side of the door with a
ligature, made from bedding, around his neck and tied to the corner of the
emergency light. He said he and the SO cut the ligature and the SO started CPR.
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66. A Custodial Manager (CM) (Oscar 1 – the senior officer in charge) arrived seconds
later and radioed a code blue medical emergency. Control room staff called an
ambulance. More prison staff arrived.
67. At 11.09pm, a nurse arrived at the cell, followed at 11.10pm by another nurse. The
nurses took over CPR.
68. At 11.20pm, an ambulance crew arrived at the cell and took over CPR.
69. BWVC footage recorded paramedics saying Mr Bugno-Swierz had a cut and that
when prison staff removed the ligature “they smacked his head”. The paramedic
said the cut was not bleeding. (Mr Bugno-Swierz’s partner provided post-mortem
photographs to the investigator that showed two cuts on Mr Bugno-Swierz’s
eyebrow and head.)
70. At 11.59pm, they declared that Mr Bugno-Swierz had died.
Contact with Mr Bugno-Swierz’s family
71. Early on 8 November, the prison appointed two family liaison officers (FLOs). Mr
Bugno-Swierz’s partner lived in Liverpool, so a FLO asked staff at HMP Liverpool to
assist.
72. At around 10.00am, two family liaison officers from Liverpool visited Mr Bugno-
Swierz’s partner and told her of Mr Bugno-Swierz’s death.
73. Both FLOs kept in contact with Mr Bugno-Swierz’s partner over the following days,
offering support and advice.
74. The prison contributed to the costs of Mr Bugno-Swierz’s funeral in line with
national policy.
Support for prisoners and staff
75. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
76. After Mr Bugno-Swierz’s death, two prison managers 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.
77. The prison posted notices informing other prisoners of Mr Bugno-Swierz’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 Bugno-
Swierz’s death. Prisoners A and B were provided with support.
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Post-mortem report
78. We have not yet received the post-mortem report.
79. The toxicology report showed alcohol in Mr Bugno-Swierz’s system at the time of
his death at twice the legal level for driving. No other illicit substances were
detected.
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Findings
Assessment of Mr Bugno-Swierz’s risk
80. 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 should be followed when a prisoner is identified as being at risk of
suicide and self-harm. It sets out the risk factors and triggers that could indicate
increased risk.
81. Mr Bugno-Swierz was never supported using ACCT. Mr Bugno-Swierz’s friends told
us that Mr Bugno-Swierz did not have a history of suicidal thoughts or self-harm,
that he told his friends he was due to be released within a month and had been
making future plans with his partner and son. We are satisfied that he gave no
indication to staff that he was at risk of suicide or self-harm.
82. Mr Bugno-Swierz’s death occurred around the anniversary of his brother’s murder.
We are unable to assess whether the anniversary of his brother’s death was a
trigger for Mr Bugno-Swierz.
83. Based on the fact that Mr Bugno-Swierz had been drinking hooch with two friends
and that they all went on to tie ligatures around their necks while under the
influence, it would appear that the hooch was the trigger for Mr Bugno-Swierz’s
actions. Neither Prisoners A nor B could help to understand why the three men tied
ligatures around their necks that night. Both said that they could not remember why
they had done so.
Delays in staff finding Mr Bugno-Swierz
84. There were several issues that led to delays in staff realising that Mr Bugno-Swierz
was hanging in his cell. Officer A told the investigator that when he went to check
on Mr Bugno-Swierz, the emergency light in his cell was not working properly. Due
to the vulnerability of prisoners in the CSU, it is vital that safety features such as
emergency lights work properly.
85. The prison told us that accommodation fabric checks (AFCs – to assess the
security safety of the cell) had been carried out on the cell and no issues were
identified. We cannot say for sure whether the emergency light was faulty when the
AFCs were conducted but it is possible it was.
86. We also note that Officer A’s radio had run out of battery so he had to leave the
CSU to change his battery and speak to the SO. Officer C then tried to check on Mr
Bugno-Swierz but said he could not see clearly because of the defective emergency
light. He said he went to find a torch but could not find one.
87. We consider that these issues indicate that working practices in the CSU are not as
good as they should be, and we bring them to the Governor’s attention.
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Hooch
88. Mr Bugno-Swierz had a history of being involved in the illicit economy in prison. On
the day of his death, Mr Bugno-Swierz had a significant amount of hooch in his cell,
which he and his friends were drinking.
89. The Deputy Head of Security at Wandsworth told us that data suggested that
Eastern European prisoners most frequently used hooch. (Wandsworth has a high
number of Eastern European prisoners.) He said that in October and November
2023, there were 15 intelligence reports submitted related to hooch, following
accommodation and fabric checks (AFCs) and staff smelling hooch. He said
searches found 110 litres of hooch.
90. HM Inspectorate of Prisons (HMIP) found in their 2021 inspection that Wandsworth
had a good drugs strategy, which covered illicitly brewed alcohol.
91. Wandsworth has since introduced a Psychoactive Substances and Alcohol Strategy
– February 2023/24. The strategy focuses on informing prisoners and staff of the
risks of alcohol, reducing access, holding those involved in supply and use of
alcohol to account, and supporting prisoners who are in the destructive cycle of
alcohol misuse. The Head of Reducing Reoffending told us that at Wandsworth,
Change Grow Live (CGL) continued to assess all prisoners’ substance misuse
needs during the second day reception screening, and follow up with assessments
and support where needed, including alcohol specific programmes/workshops.
92. She said prison staff have reduced the supply of bread and sugar (key ingredients
in hooch brewing) to prisoners. The Head of Reducing Reoffending said staff had
continued to focus on AFCs, which included the addition of tamperproof stickers on
toilet panels where hooch and hooch brewing equipment are traditionally stored.
She said the prison was working closely with the Regional Dog Team who, when
onsite, were utilised for hooch specific searches.
93. The Head of Reducing Reoffending said that hooch continues to be a topic of
discussion during monthly Drug Strategy Meetings and where intelligence suggests
particular wings have a prevalence of hooch, CGL will circulate hooch-specific harm
reduction material.
94. It is clear the hooch problem at the Wandsworth is significant and complex. We are,
however, satisfied that appropriate strategies and practices are being employed by
the prison to address this problem.
Clinical care
95. The clinical reviewer concluded that the care Mr Bugno-Swierz received at
Wandsworth for his physical health and substance misuse was of a reasonable
standard and at least equivalent to that which he could have expected to receive in
the community. However, she concluded that the resuscitation attempts were not of
the required standard and therefore not equivalent to that which he could have
expected to receive in the community.
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96. The clinical reviewer watched body worn video camera (BWVC) footage of
healthcare staff conducting CPR on Mr Bugno-Swierz. She identified the following
concerns:
• The speed and depth of chest compressions conducted by the attending
healthcare team were too fast and too shallow.
• Individuals conducting compressions did not rotate frequently (frequent rotation
prevents exhaustion and insufficient compressions).
• A pillow was seen under Mr Bugno-Swierz’s head during resuscitation efforts,
this would have compromised the airway and could result in insufficient
ventilations.
97. The clinical reviewer noted that the collective effect of these issues would have
resulted in sub-optimal resuscitation.
98. The Head of Healthcare told us that staff involved in the incident had been
supported by the prison practice development nurse and Deputy Head of
Healthcare. She said staff had been asked to undertake written reflective practice in
relation to the incident to identify how they could do something differently in the
future.
99. The Head of Healthcare later met with both emergency nurses and discussed the
concerns raised about the resuscitation attempt. She noted that she will be
providing a supportive learning and development plan for both nurses, and that
once this has been completed, they will be able to return to their role of emergency
response.
100. We are satisfied by the action of the Head of Healthcare to address the concerns
with the resuscitation attempt on Mr Bugno-Swierz. We make no recommendation.
Key work
101. All prisoners in the male closed estate are supposed to receive weekly key worker
sessions. However, since arriving at Wandsworth, Mr Bugno-Swierz did not receive
any key worker sessions. He had received key worker sessions at previous
establishments.
102. The Head of Reducing Reoffending told us that because of staffing levels, and to
provide the best regime and access to purposeful activity, key work had been
suspended since COVID-19.
103. The Head of Reducing Reoffending said re-introducing keywork had been included
in Wandsworth’s 2024/25 business plan, but while staffing levels were reduced,
only priority prisoners would receive key work. Once staffing levels allowed, all
prisoners would receive key work.
104. It is difficult to say whether Mr Bugno-Swierz would have shared any risk related
information with a key worker. Mr Bugno-Swierz’s friends had no idea that he was a
risk of suicide. It is possible therefore that key worker sessions would have made no
difference to the outcome for Mr Bugno-Swierz. Nevertheless, key worker sessions
Prisons and Probation Ombudsman 13
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are important in establishing good relationships between prisoners and staff and
should be resumed as soon as staffing levels allow.
Inquest
105. At the inquest, held from 31 March to 4 April 2025, the jury concluded that Mr
Bugno-Swierz died by suicide. They found that he was under the influence of
alcohol which impacted his decision making.
14 Prisons and Probation Ombudsman
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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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