Why was no one curious about Aleksandras Maslennikovas?

The death of Alekandras Maslennikovas (AM) illustrates a total lack of professional curiosity from officers or health providers in the prison. They saw a man who had caused no trouble for thirteen months, suddenly start to show signs of extreme depression and fear and hurt himself in a serious suicide attempt, but took no interest in why. Why? They said they liked him, and he told them that it had been a mistake.

AM was 47 and a Lithuanian. He was arrested in Britain because he was wanted in Lithuania and was waiting to be extradited. When he arrived in Wandsworth, he admitted a history of depression and anxiety and that he was drug dependant and wanted help. He successfully undertook treatment for addiction. He had no further issues with the system.

AM had been in prison for 13 months without problems when he made four severe cuts to his left arm which required stitching. These cuts were so severe that the jury at the inquest were warned before looking at photographs, and the prison contemplated whether he could be treated in house or whether he would need to go to hospital for stitching. These were not the scratches; they required double and triple layers of sutures.  When asked why he had made them, AM told his nurse that  he was under threat from others, and a file was opened, called an ACCT (Assessment, Care in Custody and Teamwork), intended by the prison service rules to direct officers in the care needed to protect him. The ACCT was opened on the evening of 12/7/23 , but was closed  on the morning of 13/7/23 by two officers sitting with him. No member of the nursing team or mental health team were present, and no one specially trained for more intimate conversations had sat in a one-to-one conversation to ‘get to the bottom ‘of anything. The prison employs officers specially trained for this. Instead, AM was asked by officers how he felt, and he said he was OK, it had all been a mistake, he was looking forward to seeing his children.

On the night of 14 to 15 July, AM and his cellmate set a fire in their cell with some wastepaper, and said they needed to move off the wing they were on. The officer on duty knew them as decent, the cell was unliveable, so they were moved separately to another wing.  By chance, AM went to share with a man he already knew and apparently liked. No ACCT was reopened, no detailed questions were asked.

On the morning of 17 July, the new cellmate went to court at 7.00am. AM was up and about and helped officers pack his cellmate’s possessions. At 8.30 am, another prisoner went to the cell to speak, looked around papers that had been put in the glass observation panel, and saw AM hanging.

But that is not the end of the mystery. The toxicology report prepared after death showed that AM had taken an enormous overdose of a drug -an ‘off the scale’ overdose, of a drug which when it was prescribed in the prison was always delivered crushed as powder to prevent it being sold ‘second hand’.  The inquest was not able to decide whether AM died of the overdose (he had taken 129 units when previous lethal doses were said 20), or whether he died of asphyxiation cause by hanging. Both were given by the jury as a cause of death; both were lethal of themselves.

So, the inquest found that suicide was the cause of death, but the death highlighted many issues, how did a prisoner get hold of such a quantity of a lethal drug when in prison, where had it come from? And why had AM never been asked about the threats which surrounded him, and his desperation to escape the wing or die. Why had no one really bothered with a man so clearly in trouble? A man who had severely slashed his arm and then attempted a cell fire.

An inquest simply answers certain questions. Who has died, where they died and the causes of death. It isn’t the coroner’s job to be a detective and establish why that person felt their only option was suicide, or who was smuggling what to whom and how involved was the deceased.  

We all left this inquest knowing that we had seen one of the tragic consequences of the uncontrolled drug smuggling activity in the prison, and that whatever opportunity the prison had had to investigate who was involved in it had been ignored and lost. A desperate man had been ignored, in the press of a crisis of lack of staff and increasing numbers of prisoners, and a chance to catch his suppliers and threateners was simply not seen or used. A total lack of professional curiosity was revealed, about the desperation in the heart of an otherwise balanced man, and about why he was threatened and what was going on around him.