HMP Wakefield’s emergency response to inmate found hanged in cell ‘delayed and ineffective’
A report found delays were due to ‘a lack of confidence and leadership’
HMP Wakefield’s emergency response to an inmate found hanging in his cell was “delayed and ineffective”, a report has found.
Pavlo Lapshyn, who was serving a life sentence for a racist murder and bombing mosques, was found hanged in his cell on September 23.
The 37-year-old Ukrainian national had some risk factors for suicide and self-harm, a report into his death said, but staff had “no reason to consider him at imminent risk of suicide”.
However, the Prisons and Probation Ombudsman, Adrian Usher, said the emergency response from the Wakefield Category A prison was “delayed and ineffective” and “far below expected standards”.
While the Ombudsman could not conclude that the delays impacted to Mr Lapshyn’s death, Wakefield prison was found to have a “clear risk” for future incidents.
During a routine check at 1.59am on September 23, a prison officer found the observation window in Mr Lapshyn’s cell covered, and they could not get a response from him.
There was a delay in immediately informing the prison’s custodial manager (CM), as is Wakefield’s Local Security Strategy, and in opening the cell door and radioing a ‘code blue’ which would have promptly alerted healthcare staff.
When the custodial manager arrived and did open the door, the report found that “staff did not immediately enter and cut the ligature or assess Mr Lapshyn for signs of life”.
It was not until 2.25am that healthcare staff arrived. The nurse completed an assessment and concluded there were no signs of life, and the officers stopped CPR.
Paramedics arrived at 2.45am and confirmed Mr Lapshyn’s death at 2.50am.
The Ombudsman Mr Usher said: “Delays occurred due to a lack of confidence and leadership. While I cannot say that these delays affected the outcome for Mr Lapshyn, they present a clear risk for future incidents.
“A robust training and improvement package for Wakefield’s emergency response will be essential.”
Mr Usher added that he was “disappointed” in the lack of support offered to staff following the incident.
However, he praised staff at the prison’s Mulberry Unit, who had worked to support Mr Lapshyn, who had autism, and build a “strong and positive relationship with him.”
The report made recommendations to the prison’s Governor to review its emergency response to ensure all prison staff are trained and understand their responsibilities during medical emergencies, and that prison leaders share learnings from serious incidents with staff.