Vilhelmas BORKERTAS · Prevention of Future Deaths report

On 25 November 2016, one of my assistant coroners, Richard Brittain, commenced an investigation into the death of Vilhelmas Borkertas, aged 24 years. The investigation concluded at the end of the inquest on 26 October 2017. The jury made a narrative determination, which I attach.

Mr Borkertas took his own life on 21 November 2016. His cellmate described waking up in the evening needing to use the toilet, putting on the light and finding Mr Borkertas hanging by a ligature from the window bar.

The cellmate rang the cell bell.

It was answered by an operational support grade 21 minutes later. The OSG then called for assistance and Mr Borkertas was cut down when other members of staff arrived. They attempted resuscitation, but this was unsuccessful.

I give a great deal of consideration at inquest to the exploration of the time it took staff to attend to Mr Borkertas after his cellmate rang the cell bell. However, I do not write about that now because I know that it is a matter already under scrutiny by the prison, and I do not think there is anything that I can helpfully add.

However, there is another matter that I should like to bring to your attention.

Mr Borkertas described himself variously as heterosexual and bisexual. The latter was recorded on his cell sharing risk assessment form. His cellmate at the time of death described himself as being homophobic. This was recorded on his cell sharing risk assessment form. However, the two were placed together in a cell and I heard no evidence that consideration was ever given to the potential dangers of this.

There is nothing to indicate that this had an impact upon the outcome, but it might be devastating in another case.