When Aleksey Baranovsky came to England he had dreams of living well. In less than a decade those dreams turned to ash: his life became a nightmare and he bled to death, neglected and alone in a prison cell.
He arrived in 1998 from Odessa in Ukraine, on a student work-exchange programme. He had been studying to become a civil engineer and put the course on hold to learn English. The picture of the young student, above, shows Baranovsky leaning against a motor show barrier, behind him a gleaming red, £200,000 Bentley Arnage. Like thousands of other young, ambitious people from the former Soviet Union, he wanted to prosper from the opportunities opening up to his generation.
His death was not just a tragedy for Baranovsky who, with care, might still be alive. It is also a bitter example of flaws in Britain's penal system generally and failings specific to the unit where he died. The exchange programme was a sham, a front for bringing in cheap agricultural labour. It brought long hours and low pay. It also introduced the Russian mafia into his life. It was a dangerous new element which would haunt him until his death in 2006.
His family believes Aleksey was trying to free himself from the clutches of the criminals running the scheme when, in December 1998, he made an application for political asylum in the UK, stating that he was in fear of his life from Russian criminals. Despite his best efforts, his application was turned down in 2001. He was homeless and penniless, on the streets in a foreign country.
He slid into crime. In 2003, Baranovsky was jailed for seven years for a series of burglaries at top London department stores including Harvey Nichols. It seems no one questioned how a man with no history of crime could pull off raids netting more than £200,000. He was no master criminal: on one occasion he was arrested after falling asleep at the scene of a burglary.
There were signs of self-destructive urges. He struggled to reconcile his dreams of self-improvement with the bleak reality of life as a prisoner; with the shame he brought on his family who had made sacrifices to help him. His sister, Tatyana, said: "To find himself in prison in a foreign country would have been a bitter blow and would have made him feel like he had failed."
Fearful of reprisals from Russian organised criminals, Baranovsky was moved to seven different prisons. He cut himself, often using razors and apparently declining medical treatment. He went through periods of refusing food and becoming withdrawn.
When Baranovsky was moved to the privately run HMP Rye Hill, near Rugby, early in 2006, he was pitched into a prison struggling to cope with what inspectors called "a challenging prison population". Lack of staff meant that two officers were in charge of up to 80 inmates on each of the eight units which housed up to 660 prisoners in the category-B prison. Inmates included the only terrorist arrested during the 1980 Iranian embassy siege and hardened criminals who staged the Strangeways prison riots in Manchester in 1990.
Aleksey was meant to see a doctor within hours of arrival. Dr Colin West, who eventually saw him, was doubtful about depression and saw no link between self-harm and mental illness. Dr West requested a mental health assessment but this was never carried out, leaving a vulnerable man with a history of self-harm at risk. A mental health assessment is mandatory for prisoners on suicide watch, as Baranovsky was for six weeks before his death.
Angela Pereira was the healthcare manager at Rye Hill. With 20 years' experience as a mental health nurse, she was responsible for managing Baranovsky's care and directing the team. When she met the young man for the first time on 9 June, just hours before he died, he asked her for a doctor. She did not follow up on this. Neither did she remember being told that Baranovsky's mother had died, although she did attend a meeting where staff were given the news. A subsequent investigation by the Prison and Probation Ombudsman concluded that she failed to provide the standard of care reasonably expected of someone in this crucial role.
Similar criticisms were made of Rye Hill's medical provision 12 months earlier when inmate Michael Bailey killed himself while on suicide watch. Bailey displayed signs of severe psychosis, on one occasion being left naked reciting the Lord's Prayer in the prison's exercise yard. Again Dr West was involved in the case.
Despite repeated instances of self-harming and being put on suicide watch, a male nurse who was supervising Baranovsky only checked on him through a window in a closed door. Although he observed Baranovsky lying on the cell floor, unable to reach the bed, and struggling to stand to collect a glass of water which he had requested, the nurse didn't think to raise the alarm. He later explained that he had no idea how ill Baranovsky was – perhaps because there was no care plan and erratic documentation of his case.
The consequences of this and many other failings in his care meant that Baranovsky had dangerously low blood pressure when he collapsed. On one occasion in the weeks before his death, he was left in a blood-covered cell for 19 hours. At the end, when it was eventually spotted that Baranovsky was not breathing, it took staff nearly 20 minutes to open the door.
Tom Osbourne, deputy coroner for Northamptonshire, was blunt in his assessment of the four months Baranovsky spent at Rye Hill. At the end of the inquest into Baranovsky's death last month, he described the young man's treatment as "shameful and appalling".
The inquest jury heard the concerns of Stephen Shaw, the prisons ombudsman responsible for investigating deaths in custody since 1999. He raised several concerns, particularly the practice of prison staff monitoring prisoners on suicide watch through closed cell doors. This had been the focus of his criticism into the controversial death Michael Bailey at Rye Hill in early 2005. The ombudsman's report stated the "practice was unacceptable then, it remains unacceptable now".
While the officer who raised the alarm, Sue Johnson, was praised for her compassion, other staff were severely criticised in the ombudsman's report, which recommended that four staff should be investigated and, if necessary, their performance referred to professional bodies.
As the doctor responsible for Baranovsky's clinical care, Colin West warranted special attention. In its report, the ombudsman concluded it had serious concerns about Dr West's clinical management and made a recommendation that Primecare, the company that provides healthcare to Rye Hill – which is run by the security firm G4S – should carry out an investigation and consider referring the case to the General Medical Council.
An internal report, in an inquiry conducted by Primecare, made no mention of action being taken against the four staff involved. When interviewed by the ombudsman, Dr West spoke of his doubt about the diagnosis of depression within a prison setting, and his view that lots of people are on antidepressant medication inappropriately, adding: "You have to take it on the chin. That's life."
Dr West retired from general practice within the NHS in April 2006. He remains on the General Medical Council register for doctors in the UK. A spokesman for the Medical Defence Union, which acts for Dr West, declined to comment on the case, citing patient confidentiality.
Last month, an inquest jury returned a damning narrative verdict outlining a catalogue of failures. It highlighted failures to follow policy on suicide prevention, to arrange an urgent psychiatric assessment, to provide a treatment plan as well as a lack of communication between staff.
Jocelyn Cockburn, the lawyer representing the family, welcomed the verdict. "We hope lessons have been learnt... to ensure the appalling level of care Mr Baranovsky received is not inflicted upon any other prisoner at Rye Hill or any other prison."
Copies of the report into the deaths of both Baranovsky and Bailey were sent to the Home Secretary and the head of the Offender Management Service, responsible for awarding contracts for new prisons. Deborah Coles, co-director of Inquest, which monitors deaths in custody, said: "If this happened in any other setting, this would be treated as gross professional misconduct."
The issue of where the blame lies for Baranovsky's death is as complex as the case itself; G4S, which operates Rye Hill, has implemented most of the 22 improvements suggested by the ombudsman and, in 2008, terminated its contract with Primecare at Rye Hill. Primecare deemed no action was to be taken against staff.
For the grieving family, questions remain about the role played by prison staff. Aleksey's sister Tatyana said: "They weren't doing anything to help him... just watching him die. It is very strange he was allowed to kill himself in this way." The prison took six months to advise them of Baranovsky's death, and then they had to collect his remains from their local post office.
Critics question the lack of accountability of a private healthcare system pointing to the seemingly autonomous decision of Primecare to deem its staff's action as not warranting action despite the prison ombudsman calling for robust action over the failings. Juliet Lyon of the Prison Reform Trust said: "Serious questions remain about the competence and accountability of its private providers and the private healthcare they commissioned at the time. In future such exceptional and terrible cases will fall within the ambit of the Corporate Manslaughter Act."