The death of Patryk Gladysz who fell through the cracks

Patryk was the 15^th prisoner to commit suicide at HMP Wandsworth since January 2021 and the 8^th foreign national. He died in hospital on 19 January 2024 having been found hanging in his cell on 5 January. He was 27 years old.

He was there for nine months before committing suicide and for his last 200 days officers never wrote a single entry in his record. He was invisible because he was not rude or violent or sick. Indeed, he was described by others as bright and funny, but he was also a schizophrenic who needed an injection every two weeks to keep him mentally well and to prevent him hearing voices. And twice it was forgotten, once for two weeks and then for five weeks.

Christmas and New Year are a miserable time in prison life for everyone anyway, but other prisoners said that Patryk had started to hear voices and thought he was talking to the devil. They told officers on the wing about this, but no-one took any action or even made a note. In early January he woke up one morning and decided to hang himself when his cellmate went out to work. Officers were shocked, he had never caused trouble before.  

In prison, you are supposed to have the same level of care that you would get in the community, but did Patryk get that degree of care? Only when he was dead did anyone really notice he was a schizophrenic and that he had not been medicated with enough care and appropriately. And yet the prison cannot claim ignorance. In the community he had been treated by mental health services since 2019 and he arrived at Wandsworth with court notes with “schizophrenic” marked at the top of the page - although one senior officer at the inquest dismissed this as “not proven”. The community mental health team phoned the prison to try to ensure continuity of care. His mother phoned Safer Custody and told them his medication and stressed the importance of his having it.

And yet in all the time he was there he never saw the prison psychiatrist and had minimal interventions with mental health nurses, largely performed while walking back to a cell with no thought to his language difficulties. For reasons that were never properly explained, there was a 5 week gap between his injections between November and December and possibly a 2 week gap in September. For all we know, Patryk might still be alive today if he had had these injections.  When he next received his injection on 14 December he told the nurse he was hearing voices. The nurse recorded this but took no further action as the voices were apparently ‘not derogatory’. Just the normal nice voices that people hear all the time, presumably.

Patryk spoke some English but would have found it difficult to communicate with people in the prison, especially if they spoke with a strong accent. Despite the facilities available to help prisoners with limited English, no-one used these to help communicate with him.  

A clinical reviewer found that healthcare provision for Patryk was equivalent to that he could have expected in the community. How can this be right? The healthcare provided fell far below the standard that he had already been receiving in the community. The comparison is stark.

As Patryk wasn’t on an ACTT (Assessment, Care in Custody and Teamwork - the process to ensure the safety of prisoners at risk of suicide and self-harm) and didn’t go to education or training, none of the officers on his wing noticed him. None of the officers appearing at the inquest were aware of the HMPPS instructions on foreign prisoners. They hadn’t even read the paper written by the then Head of Safety on the heightened risks posed by Foreign National prisoners, especially Polish ones. This is totally unacceptable in a prison where nearly half of the men there are foreign nationals.

What lessons are there to learn from Patryk's death? Don’t be well behaved in prison, don’t be quiet and obedient. If you are, the system is not designed to give you any attention and you will fall through the cracks, and no-one may notice until it’s too late.

Since the Ombudsman investigation the prison now reviews prisoner case notes every month and if there are no notes for that month there will be a check-in meeting with the prisoner. WPIC asks about these checks and will test how many meetings take place and the quality of these.