Investigation and inquest
On 7th September 2015 an investigation was commenced into the death of Marcin Miroslaw Mazarek aged 32. The investigation concluded at the end of the inquest on 4th October 2017. The conclusion of the inquest was that the deceased had died by hanging. The jury further found that the deceased had spent an inappropriately long time in segregation, that there had been a failure in the proper implementation of ACCT procedures, with no multidisciplinary working and no involvement of mental health and inadequate reporting by discipline and medical teams.
Circumstances of the death
The deceased had become mentally unwell which condition was exacerbated by a very long period in segregation. He began to self-harm and ultimately hanged himself.
Coroner’s concerns
(1) Medical record keeping was of very poor quality
(2) The daily medical checks in segregation by members of the nursing team and the tri-weekly checks by the GP team, were frequently not recorded in the medical notes and / or did not take place.