You are here: Ombudsman: The teenager's death in HM Wandsworth was preventable

On 20 February 2018, the Prisons and Probation Ombudsman (PPO) published the findings of an investigation into the suicide of a Lithuanian 18 year-old held in HMP Wandsworth. Having been arrested on 8th August 2016 in London for shoplifting sweets, Osvaldas Pagirys was found to be the subject of a European Arrest Warrant in Lithuania for mobile phone theft. 

Mr Pagirys’s time in custody was riddled with mismanagement and severe failures in the exercise of the prison staff’s duty of care. This included:

·       Disregard for mental ill health warning signs such as ligatures around his neck and his attempt to strangle himself.

·       Failure to provide an adequate interpreter despite his limited English.

·       Punitive responses to his escalating levels of mental distress such as moving him to a segregation unit.

Elizabeth Moody, Acting Prison and Probation Ombudsman, described the incident as ‘an appalling and tragic case’. Sadly, Mr Pagirys’ situation is entirely symptomatic of wider issues in criminal justice. Revolving Doors Agency has been involved for some time in working to improve systems for people with multiple needs. We know, for instance, that 18-24 year olds are more likely to attempt or commit suicide than older prisoners and therefore should be ‘recognised as distinct from the adult population on account of their developmental stage and because of the economic, social and structural factors that specifically impact upon them’. From our publication Rebalancing Act, we know that prisoners have a mortality rate about 50% higher than the general population and that up to 25% of the prison population have difficulties in communicating and processing new or complex information. 

In light of Mr Pagirys’ tragic and preventable death, Revolving Doors welcomes the PPO's recommendations for procedural change within prisons to identify and respond to those at heightened risk of suicide. 

However, it is imperative that this is complemented by a shift in prison (and wider criminal justice) culture so that, where appropriate, staff are equipped to understand disruptive behaviour as a manifestation or vulnerability or trauma and can therefore respond by providing support rather than attempting to manage perceived risk. We therefore call on each part of the criminal justice system to thoroughly understand the needs and vulnerabilities of young adults, particularly those who experience mental ill health and for whom English is a second language.

We continue to work with government and criminal justice stakeholders and alongside people with lived experience to turn these ambitions into reality.