Ombudsman: teenager's death in Wandsworth prison 'appalling'

The death of a distressed Lithuanian teenager in the segregation unit of Wandsworth prison after he was arrested has been condemned as “appalling and tragic” by the prisons and probation ombudsman.

An investigation by the acting ombudsman has found that on the day of his death, Osvaldas Pagirys, 18, had rung a bell in his segregation cell but it took prison staff 37 minutes to respond – by which time he was found hanging unconscious.

The investigation also found that Pagirys had been found with a noose around his neck on five previous occasions during the three months he had been in Wandsworth.

A coroner recorded a verdict of accidental death on Tuesday following an inquest into the vulnerable teenager’s death on 14 November 2016. After being arrested for stealing sweets he was held first in Pentonville and then moved to Wandsworth pending his extradition to Lithuania on a European arrest warrant.

Pagirys died six months after the then justice secretary, Michael Gove, had named Wandsworth, UK’s largest prison, as a key “trailblazer” in his “reform prison” movement.

In a statement after the inquest, Pagirys’s family described the support he had received as “inadequate” and said they were “shocked” it took staff so long to respond to the cell bell.

“We welcome the jury’s findings that the prison staff did not carry out timely checks on Osvaldas, that there was a delay in responding to the emergency cell bell and that this did contribute to his death.

“Our hope is that Osvaldas’s death has made the management at HMP Wandsworth and the Ministry of Justice pay close attention to the management of those at risk of self-harm and ensure that there is adequate supervision of staff.”

Elizabeth Moody, the acting prisons and probation ombudsman, who also carried out an inquiry into the death, said: “The circumstances of Mr Pagirys’s death were appalling and tragic.

“He was a vulnerable, 18 year-old Lithuanian man who found it hard to cope with prison life and to communicate in English. Staff responded to his increasing levels of distress punitively and he was subject to an impoverished, basic regime during much of his time at Wandsworth.”

Pagirys was anxious about the prospect of being returned to Lithuania when all his family lived in Croydon, her investigation found.

Moody said Wandsworth staff had not satisfactorily acknowledged his vulnerability or taken inadequate action to tackle his deteriorating mental health, and had failed to manage his suicide risk..

“It is emblematic of the poor care that Mr Pagirys received at Wandsworth that it took 37 minutes to respond to his cell bell prior to discovering him hanging in his cell,” she said.

The ombudsman inquiry report findings state: “The delay in responding to Mr Pagirys’s cell bell on the day he was discovered hanging was unacceptable. Cell bells should be answered promptly, certainly within five minutes. Had staff responded to [his] cell bell within that timeframe his life might have been saved.”

The teenager had been repeatedly assessed as not suffering from significant mental health problems after being interviewed without an interpreter, despite struggling with his English. On the one occasion when he was interviewed with a professional interpreter, a GP had concluded he did not need mental health treatment.

He had been found with a noose around his neck on five previous occasions before his death, including on the day that he was declared fit for segregation. That decision was taken after what the ombudsman called “a woefully inadequate assessment” by a nurse, which failed to question the impact segregation would have on his mental health.

The prison manager who authorised the decision told the fatal incident inquiry she didn’t know Pagirys had been seen in the unit with a noose around his neck.

Pagirys was arrested on 8 August 2016 in London for shoplifting sweets and was found to be the subject of a European arrest warrant in Lithuania. Extradition proceedings started and he was refused bail and imprisoned first in Pentonville and then in Wandsworth, where he spent the last three months of his life.