Who was looking after Sebastião Lucas?
- leanlamb0
- 2 days ago
- 5 min read
This article was originally published on 11 January 2026 in Putney News which does a fine job of reporting on Wandsworth Prison. The text is reprinted here with their kind permission.
A prison watchdog has expressed shock over multiple failures at Wandsworth Prison that left a suicidal man dead just 48 hours after his arrival, with staff repeatedly ignoring warnings and missing opportunities that might have saved his life.
Sebastião Lucas died by hanging on 12 May 2021, two days into his time at the South London jail. A damning Prisons and Probation Ombudsman report [pdf] published this week found staff failed to assess Mr Lucas’s risk adequately or keep him safe, despite him arriving with documents showing he had been under constant supervision and had stated he would kill himself.
The clinical reviewer concluded Mr Lucas’s mental healthcare “was not adequate or equivalent to that he could have expected to receive in the community.” Oxleas NHS Foundation Trust, which provides all healthcare services at Wandsworth, was responsible for Mr Lucas’s medical and mental health care.
An inquest in September last year ruled the Wandsworth Prison death was suicide contributed to by neglect.
Clear warnings ignored from arrival to death
Mr Lucas arrived at Wandsworth on 10 May 2021, after allegedly assaulting a hospital nurse while being sectioned under the Mental Health Act due to suicidal thoughts. He came with a Person Escort Record noting he had been kept under constant supervision in court custody and had said he would self-harm or kill himself.
Despite this, the reception officer did not open suicide prevention procedures (known as ACCT) when she spoke to him. The ombudsman said it was shocked the officer was not aware of repeated warnings that staff too often assess prisoners’ risk based on how they appear rather than their documented risk factors.
A nurse then assessed Mr Lucas at 4.52pm. She did not see his escort record or suicide warning form. Mr Lucas told her he was going to kill himself and had not made plans but would “use whatever it took.” The nurse opened an ACCT at 6.15pm, more than an hour after identifying the risk.
During reception, a body scan revealed Mr Lucas had a substantial quantity of suspected drugs secreted inside him. This information was not adequately communicated or considered when assessing his suicide risk or potential threats from other prisoners. Prison policy for dealing with prisoners who have secreted items did not cover situations where items had already been confiscated.
A manager did not complete Mr Lucas’s immediate ACCT action plan until nearly midnight, some six hours after the procedure opened and nine hours after he arrived with a suicide warning form.
System failures
The next day, an officer, a custodial manager and a mental health nurse completed Mr Lucas’s ACCT assessment and first case review together. Prison Service policy states these must be conducted separately. None of the staff knew about the confiscated drugs.
The nurse had not reviewed Mr Lucas’s medical records before the meeting, which contained crucial information about his recent psychiatric history. After the review, she accessed these records and added him to the mental health team’s caseload.
That afternoon, a mental health practitioner from South London and Maudsley liaison services emailed Wandsworth’s mental health team with detailed information about Mr Lucas. The email noted he had been assessed for admission to a psychiatric bed before his arrest, had told staff he would kill himself if not admitted to hospital, and had expressed paranoid beliefs. The team did not act on this information or conduct an urgent review of Mr Lucas’s care plan.
Staff assessed Mr Lucas as “raised risk” and kept him on hourly observations. His care plan contained just one action: getting him a television.
On 12 May, several staff spoke to Mr Lucas that morning. An officer gave him lunch at 11.42am and noted he had no issues. No one checked him after that. Around 12.15pm, a supervising officer asked three officers covering the wing over lunchtime to also cover the first night centre where Mr Lucas was located. Staff failed to complete ACCT observations between 11.42am and 2.26pm, when an officer discovered Mr Lucas hanging in his cell.
Officers cut him down and began resuscitation. Staff in the control room called 999 but incorrectly told the operator Mr Lucas was breathing. Paramedics arrived at 3.36pm and pronounced him dead at 3.42pm.
Inadequate assessments
The ombudsman found nobody in the prison made a sufficiently informed or accurate assessment of Mr Lucas’s level of risk. Staff should have considered his risk factors more carefully and observed him more frequently than hourly, especially during his first days in custody.
The ombudsman said: “Mr Lucas had been treated as a high risk to himself in hospital, police custody and court custody and was being dealt with urgently. I am dismayed that once he arrived at Wandsworth the need for the same level of urgency and for acute care was not recognised.”
The report added: “We cannot say whether better risk assessment and a greater sense of urgency would have saved his life, but it may have done.”
Mr Lucas’s death was the fourth of seven suicides at Wandsworth in just over six months. The three suicides which followed are still being investigated by the ombudsman.
The prison made six recommendations, all accepted by HMP Wandsworth and healthcare provider Oxleas NHS Foundation Trust. Key changes include ensuring reception staff consider all risk information, ACCT assessments and reviews are conducted separately, observations take place as specified, and information about confiscated drugs is properly communicated.
A Prison Service spokesperson said the prison has strengthened how it assesses and manages suicide risk, introducing closer working between teams to support new prisoners, and ensuring staff receive daily lists of those at risk.
Pattern of deaths at HMP Wandsworth
Mr Lucas was one of multiple people who have died at Wandsworth in recent years. This publication has reported on several cases where the Prisons and Probation Ombudsman found serious failings.
Name | Age | Date of Death | Cause | Key Finding | Story Link |
Sebastião Lucas | 34 | 12 May 2021 | Self-inflicted | Suicide contributed to by neglect; staff failed to assess risk adequately despite clear warnings | This report |
David Wise | 46 | 15 Dec 2021 | Non-natural | Systemic failures in care and oversight | |
Rajwinder Singh | 36 | 20 June 2023 | Self-inflicted | Father of three who would still be alive if sent to different prison; staff falsified records, ignored emergency bell | |
Patryk Gladysz | 27 | 19 Jan 2024 | Self-inflicted | Man with schizophrenia failed by catastrophic errors | |
Rana Khan | 60 | 5 April 2024 | Natural causes | Let down by inadequate emergency care; staff failed to manage cardiac emergency properly | |
Thanweer Asharaf | 26 | 23 June 2024 | Natural causes | No prison fault found in death of 26-year-old | |
Peter Honnor | 55 | 27 June 2024 | Natural causes | Poor quality CPR, no CT scan after head injuries, night patrol had no cell key |
This table includes deaths at HMP Wandsworth where Putney.news has published detailed coverage of Prisons and Probation Ombudsman reports.
Since June 2021, there have been 20 deaths at Wandsworth: six from natural causes, ten self-inflicted, three drug-related, and one additional self-inflicted death since June 2024. Multiple investigations remain ongoing.
The pattern of deaths and systemic failures at Wandsworth raises questions about whether the prison can provide adequate care for vulnerable prisoners with complex mental health needs.
The Prisons and Probation Ombudsman investigation included interviews with 15 staff members. Both HMP Wandsworth and Oxleas NHS Foundation Trust accepted all six recommendations in their action plan [pdf].
