Recipient

Bullingdon Prison

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First report 21 Jul 2014•Latest report 21 Jul 2014

Recipient record

Reports, concerns and published responses

Justice · Prison or young offender institution. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Bullingdon Prison linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Oxfordshire

    AI-generated summary

    Marcin Jack STOGA · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Marcin Stoga had been held on remand at HMP Bullingdon since November 2012 and was found hanging in his cell on 24 April 2013, the day after attending court. Concerns included information about a previous overdose not being available during his initial assessment, and prisoners with mental health difficulties or a medium/high risk of self-harm not being routinely assessed after returning from court. The inquest jury confirmed suicide and identified missed opportunities to support him that were systemic in nature.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bullingdon Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide thorough post-court assessments for prisoners at elevated self-harm or suicide risk

    Wider context from the report

    “(2) A second concern, which is to some degree related to the first, is the fact that prisoners (particularly those with mental health difficulties or who are otherwise at a medium/high risk of self-harm) are not routinely assessed on return from court hearings. Mr Stoga attended court on 7 December 2012 and again on 11 February 2013 and 23 April 2013, the day before his death. There were no such assessments. On this last occasion it is believed that Mr Stoga was charged with assaulting his partner. I understand from evidence and information at Inquest that there has been a review (and that this issue also formed part of the PPO Recommendations) and that persons returning from court will be seen by the Duty Reception Nurse to ascertain any change in circumstances. What is not clear is if this is anything other than a cursory assessment. It appears that a more thorough assessment is likely to be required for those prisoners who have a history of mental health issues and are believed to be at a medium/high risk of self-harm or suicide. It appears there may be a need for some written guidance for staff or perhaps a protocol. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bullingdon Prison; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make relevant prisoner escort information available for initial assessments

    Wider context from the report

    “(1) Prior to Mr Stoga’s arrival at HMP Bullingdon, there was a Prisoner Escort Record which referred to the fact that Mr Stoga had taken an overdose in 2012. It appears that this form and this information was not available to the Prison Officers or the Healthcare Nurse who initially assessed Mr Stoga upon his arrival. One would have thought that the form or at least the information on the form should routinely be available to those responsible for carrying out initial assessments of this nature. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026