Patryk Gladysz
This report repeats 2 earlier warnings, and was raised again 2 times later. See the linked reports.
The coroner's concerns
1. delayed or inadequate mental health assessments
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments”
2. insufficient staffing affecting key worker responsibilities
“Staffing within HMP Wandsworth resulting in a dilution to the requirements for the key worker scheme”
3. lack of awareness of heightened risk to foreign nationals
“Knowledge of prison staff of the heightened risk of foreign nationals in custody, despite a higher proportion of foreign nationals being detained at HMP Wandsworth”
4. poor communication and inconsistent NOMIS account management
“Communication between prison and healthcare staff regarding: (a) knowledge sharing of those presenting with a serious and enduring mental health illness, such as schizophrenia; (b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and (c) de-activation of NOMIS accounts for healthcare staff due to lack of use - 21 healthcare accounts were de-activated notwithstanding an increase in available terminals”
5. inadequate roll call and ACCT observations
“Prison officer checks of roll calls/ACCT observations - recent audit by HMP Wandsworth suggests on-going challenges”
6. outdated first aid training among healthcare staff
“First Aid refresher training is not up to date for all healthcare staff”
Linked reports
Earlier report
“(4) Whilst all prison staff were trained in the use of this system and were able to access it, only some clinical staff are able to access NOMIS.”
This report
“(b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff; and”
Earlier report
“In evidence it was clear that the ACCT document was the only written document used for sharing information between the healthcare staff employed by the NHS trust and the prison security staff.”
This report
“(b) inconsistent understanding of healthcare access to the NOMIS by both prison and healthcare staff;”
This report
“Staffing within the Mental Health In-reach team impacting the timely undertaking of meaningful and quality mental health assessments.”
Later report
“There is a policy requirement / expectation that a member of the healthcare team should attend all ACCT reviews.”
This report
“First Aid refresher training is not up to date for all healthcare staff.”
Later report
“After prison officers and prison staff carry out their induction training which covers basic first aid training including the delivery of cardio pulmonary resuscitation (CPR), there is no further mandatory refresher training on first aid or CPR.”
Responses
2025-0364-Response-from-Department-for-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · late 2024
“I understand your concerns about staffing shortages within the mental health in-reach team at HMP Wandsworth, and how that may have impacted the quality of mental health assessments. I understand from NHS England that, at the time of Mr [name redacted] death, the team had a vacancy for one whole time equivalent staff member, and that this has now been filled. In addition, the internal patient safety investigation into Mr [name redacted] death carried out by Oxleas NHS Foundation Trust, as the healthcare”
2025-0364-Response-from-HM-Prison-and-Probation-Service.pdf ↗· His Majesty's Prison and Probation Service
2025-0364-Response-from-NHS-England.pdf ↗· His Majesty's Prison and Probation Service
Stated action · 15 October 2025
“Staffing within the Mental Health In-reach team”