Liridon Salikuка · Prevention of Future Deaths report

On 14 January 2020 I commenced an investigation into the death of Liridon Saliuka, age 29. The investigation concluded at the end of the inquest on 3 November 2022. The conclusion of the inquest was suicide. The medical cause of death was partial suspension.

Mr Saliuka had been a prisoner on remand at HMP Belmarsh since July 2019. He had sustained significant injuries in a car accident in 2018. He had been placed in a medical cell with a hospital bed and mattress. On 31 December he was moved to an ordinary single cell without a special bed or mattress. Mr Saliuka objected to the move because he believed he needed a special mattress to alleviate the pain from his injuries. On 2 January 2020 he hung himself in his cell.

The cell move went ahead despite a governor’s recommendation that it be postponed pending clarification of the medical assessment.

There was confusion and misunderstanding between prison staff, healthcare staff and social services as to:
• the extent of Mr Saliuka’s disability
• who was responsible for assessing it
• what adjustments were required
• who had recommended adjustments

This also created confusion for Mr Saliuka who believed that he had been assessed for a special mattress and that this entitlement was being taken away by way of punishment.

The jury’s conclusions were as follows:

• There were repeated failings to consistently recognise the fact and extent of Mr Saliuka's disability resulting in further failure to implement reasonable adjustments, specifically relating to the provisions of an adequate mattress and to conduct an adequate medical assessment, prior to completing the move from the medical cell.
• There were significant failures in the co-ordination of Mr Saliuka’s care, with inadequate record keeping.
• There were numerous instances of ill treatment of a discriminatory and dismissive nature, along with an insufficient willingness to address Mr Saliuka’s concern.
• We consider the above to have negatively impacted on Mr Saliuka's mental health and thus constitute contributing factors to Mr Saliuka’s suicide.

1. To the Governor of Belmarsh and to the Chief Executive of Oxleas. There was no clear documentation (accessible by prison staff, healthcare and social services) of the adjustments that were required for the prisoner’s disability,

2. To the Governor of Belmarsh. There was a lack of disability awareness amongst prison staff of all levels. For example, there was an assumption that a prisoner could not be disabled because he used the gym and had good upper body strength.