Why did Rajwinder Singh die?

The prison Ombudsman described the failures of Wandsworth prison to care for Rajwinder Singh as voluminous and diverse. He said that there were multiple opportunities for meaningful interventions in Mr Singh’s care that would have led to a different outcome, which were repeatedly missed. He said,

I do not make the following statement lightly, but I consider that had Mr Singh been sent to a different prison in 2023, not in such a state of crisis, he would almost certainly be alive today.

That is about as damning a statement as one will ever see coming from the Ombudsman.

So, what did that state of crisis really mean for Rajwinder?

He arrived at HMP Wandsworth on the 9th of June 2023 with a form from the Court which was intended to alert the prison to his risk of suicide or self-harm. It recommended that he be placed under constant observation; but this important and clearly identifiable form was not read by prison or healthcare staff and no safety plan was opened.

Within days it should have been obvious to everyone concerned that Rajwinder was dangerously and seriously troubled. He was twice found with a ligature round his neck; he set fire to his hair and then set fire to a mop in his cell. Each time he was moved to a different cell, and officers were told to observe him twice within an hour and to have meaningful conversations with him because he was correctly identified as suicidal. But did this happen? What expert help did he get?

At the inquest it became clear that the prison was in chaos. An officer on secondment from Wakefield described the dirt, the lack of staff to cover shifts, and her horror at finding dead rats on the wings. CCTV of the officer activity on the wings revealed that the observations intended to keep Rajwinder safe and engaged were frequently missed. There were days and nights when no checks at all were recorded, and there were certainly no meaningful conversations. The senior officer on the wing felt out of his depth and did no assurance checks. Although care was below any measure of substandard, no one in authority appeared to notice.

Oxleas, the healthcare providers were forced to admit to the inquest that

the care Rajwinder had received was certainly not equivalent to the care he should have received in the community, which is the legal test.  

When living in the community Rajwinder was on many medications for anxiety, and a heavy-duty pain relief medicine, pregabalin, taken to manage the chronic pain he suffered from fibromyalgia. This and his other medicines were not given to him whenever the prison was short of staff, and his pregabalin prescription was reduced without any discussion with him or explanation. He was left anxious, confused and in pain.

Eventually one very superficial mental health assessment was done, by an agency nurse who failed to read his file, failed to make notes of the case until after his death, and who decided on the basis of a short conversation that Rajwinder was a ‘faker’.

Rajwinder was finally held in a cell that was described by prison staff as squalid. He was moved there from another cell which the head of Safer Custody at the time described as indecent because in a hot week in June, it had no sink or access to water and should have been taken out of service. Although he was known to be suicidal and in mental turmoil he was held there alone with no TV or telephone and despite the prison instructions to be on regular observation, he was not observed.

In the final evening CCTV from the prison showed that prison officers left their shift before it officially ended having been missing from the wing for some time. When they left many prisoners cell bells were unanswered including Rajwinder’s. The officers concerned falsely recorded that checks had been made on Rajwinder when they had not. The officer who took over from them was only a ‘support officer’, relatively untrained and inexperienced, and there was no hand over briefing.  He began his shift answering the prisoners’ bells in order as he came to them and he found Rajwinder about twenty minutes later, all but dead.

Rajwinder finally died in Saint George’s Hospital Tooting five days later with serious brain damage caused by lack of oxygen. He leaves a wife and three small children.

Members of WPIC attended the inquest and one of the most moving aspects of the scene was to see Rajwinder’s wife each day bravely ‘hanging on’. We cannot imagine what she felt hearing the evidence. It appalled us that so few of the prison witnesses had the empathy to say that they were sorry for her loss, however trite the words, that should be said.

She described her husband as a kind man who helped in both her church and his own Gurdwara, and who was fun to be with and was liked by all.  We shuddered as she described a phone call she made to the prison only days before he died, explaining how ill and troubled he was and her fears for his well-being. The call was not courteously received; her message was ignored.

What did the inquest conclude?

The inquest of a person who dies in the custody of the state is held by a coroner with a jury. The coroner conducts the investigation; the jury listen to the evidence and make the findings.

After hearing evidence for two weeks the jury concluded that Rajwinder did not intend to take his life and died by misadventure contributed to by neglect.

The jury also found that the following probably contributed more than minimally to the death:

• The reduction of his medication pregabalin and the failure to communicate this to Rajwinder.

• The inconsistent provision of Rajwinder's medication and the consequent effect this had on his physical and mental health.

• The failure to provide Rajwinder with adequate mental health support.

• The failure to answer Rajwinder’s cell bell within the required 5 minutes on the night.

The jury also found that the failure to conduct the required observations on a suicidal person on the night possibly contributed to the death.

This is a finding of neglect of a prisoner in acute distress by the prison.  It is an unusually serious finding.  The coroner will make a Prevention of Future Deaths Report at the end of October.