Severyn Witold Glowinski · Prevention of Future Deaths report

On 9th July 2013 I commenced an investigation into the death of Severyn Witold Glowinski then aged 25 years.
The investigation concluded at the end of the inquest on 15th October 2014.
The conclusion of the inquest was a narrative conclusion the medical cause of death being hanging.

Mr Glowinski was a serving prisoner at HMP Long Lartin in Worcestershire. He was diagnosed with paranoid schizophrenia and for his own protection was transferred from normal location into the segregation wing.

Although it was anticipated he would only be on segregation for a matter of days he stayed there for a little under a fortnight.

He was found hanging in his cell on the evening of 3rd July 2013. Mr Glowinski was the subject of an open ACCT because of self-harm.

(1) There appeared to be no communication between the Residential Wing and the Segregation Unit as to the plan for Mr Glowinski. It appeared that the Segregation staff were unaware that the wing staff wanted to have him risk assessed for a move to another location and in fact the risk assessment was not commenced until the day before his death.

(2) The documents to review and authorise his further detention in the Segregation Unit were completed by the way of "cutting and pasting" from other prisoner's files. It was clear that the information on Mr Glowinski's paperwork was incorrect and had been transposed from another prisoner.

(3) The Senior Custodial Managers in the wing were unaware of the requirements of prison service orders which meant that an individual on an open ACCT should not be transferred to segregation unless there were exceptional reasons for doing so.