The inquest into the death of Tomasz Nowosad has concluded his death was contributed to by neglect as it is revealed that there has been 29 self inflicted deaths at HMP Manchester since 2006.
The inquest into the death of Tomasz Nowosad concluded on 6 December 2019. Tomasz sadly died on 2 February 2017 at HMP Manchester aged 27 years old.
Tomasz was born in Poland and moved to the UK in 2013. He was diagnosed as suffering from paranoid schizophrenia and in 2016 he was sectioned twice under the Mental Health Act. He entered HMP Manchester in September 2017 having being charged with GBH, which was suggested may have been an incident linked to his mental illness. Shortly after entering HMP Manchester, Tomasz disclosed experiencing paranoid and delusional thoughts and subsequently requested to see a health professional related to his paranoia. Despite making this request in November he was not seen until December. In January 2017 he again disclosed experiencing paranoia and was moved to the healthcare unit at the prison and put on an ACCT (Assessment, Care in Custody and Teamwork care plan) designed to monitor his risk of self harm and suicide.
On 30 January 2017 an ACCT review was held where it was documented that Tomasz felt safe on the healthcare unit but if he was to be returned to the wing he would develop suicidal thoughts. On the same day, Tomasz was seen by a Consultant Forensic Psychiatrist who deemed him fit for discharge from healthcare on the basis that he was being moved to the Vulnerable Prisoners Unit.
On 1 February an ACCT review prior to discharge from healthcare was held. A prison officer who spoke Polish was used as an informal translator and it was discussed that Tomasz would be moved to the induction wing at the prison. The healthcare staff thought that he would be placed on the segregated part on the wing for vulnerable prisoners, however, he was placed with the general population and prison staff on the wing were not made aware of Tomasz’s health needs nor his disclosure, two days prior, where he threatened to take his own life. Tomasz’s ACCT risk level was kept at low during this review. It came to light during the inquest that the healthcare staff did not know the exact details of Tomasz’s discharge and had they known this, the Deputy Inpatients Manager at HMP Manchester said she would have assessed the risk as high and would have stopped Tomasz’s discharge from the wing.
Sadly on the evening of 2nd February Tomasz was found in his cell having ligatured and was unresponsive to resuscitation attempts.
The conclusion of the Jury as to death was suicide contributed to by neglect. The jury found the following:
Meetings between Tomasz and the Consultant Forensic Psychiatrist were not uploaded until 1 February and 8 February 2017 and these contained vital clinical information which other members of healthcare could not access;
Despite Tomasz having varying levels of English comprehension during his time at the prison, the interpretation tool available to staff was not used on a consistent basis;
The lack of understanding between clinical and prison staff in transferring Tomasz was critical especially in view of the comments made during the review on 30 January during which he stated he may harm himself if moved back to a normal location;
Tomasz’s ACCT review was not considered or reviewed by prison staff in sufficient detail in order to fully understand his mental state.
Tomasz’s death is sadly not the first at HMP Manchester where failings of the prison and healthcare procedures have been highlighted. The Prison and Probation Ombudsman have previously raised concerns in their investigations following deaths in prison about reliance by staff being placed on a prisoner declaring no thoughts of self harm or suicide and this not being looked at in the wider circumstances of their mental state or health conditions when risk assessing.
The Coroner has a responsibility to decide whether to take steps to try and prevent future deaths with regard to the evidence heard in inquest proceedings. In light of the evidence heard and the jury’s findings, HM Senior Coroner for Manchester City, Mr Meadows, is going to issue a Prevention of Future Deaths report which will address the issues raised in this inquest, such as the process of record keeping, concerns in relation to risk assessing and properly documenting this assessment, the use of interpretation services.
The family of Tomasz Nowosad were represented by Kelly Darlington of Farleys Solicitors LLP and Kate Stone of Garden Court North Chambers. If you require legal advice relating to the inquest of a family member, please contact Farleys’ inquest team on 0845 287 0939 or email us through our online contact form.