The treatment of a Ukrainian man who died while on suicide watch in a British prison was "appalling and at times unacceptable", a coroner said today.
Assistant deputy coroner for Northamptonshire Tom Osbourne made his comments as a jury found there were serious failures and inadequacies that contributed to the death of Aleksey Baranovsky at HMP Rye Hill, Warwickshire, in June 2006.
The 33-year-old repeatedly self-harmed during his time at the prison and was found dead in his cell by staff in the early hours of June 10 that year, the inquest heard.
The inquest, at Rushden and Diamonds Football Club in Irthlingborough, Northamptonshire, heard that Baranovsky was due to be deported upon his release and made "a sort of protest" by repeatedly cutting himself.
The hearing was told that Baranovsky, who was transferred to privately-run Rye Hill in February 2006 after serving the early part of his seven-year sentence in other jails, was placed under suicide and self-harm (Sash) watch.
He was moved to the healthcare unit of the prison while his blood-covered cell was cleaned, but repeatedly refused treatment.
After being placed on constant supervision, Baranovsky was found unconscious, kneeling on the ground in his cell, with his head and arms resting on his bed, at about midnight on June 9, 2006.
Ambulance crews rushed to the scene but all efforts to resuscitate him failed, and he was confirmed dead at around 12.40am on June 10.
The jury heard that he "eventually lost so much blood that was not replaced, he died".
Returning a narrative verdict today, the jury of seven men and two women found inadequacies and failures contributed to his death.
It said: "Aleksey Baranovsky died in his cell in the healthcare unit of Rye Hill Prison after a prolonged period of deliberate self-harm by way of cutting himself and regularly refusing food.
"This was during the period from April 22, 2006, until June 10, 2006. During this time Mr Baranovsky repeatedly refused medical attention."
The jury found that several factors contributed to the Ukrainian's death, including a failure to carry out an adequate mental health assessment, or full and adequate health assessment at any time he was at Rye Hill.
They also said there was a failure to assess healthcare needs and draw up a detailed care plan, as well as inadequate systems and processes regarding verbal and written communication between healthcare staff, prison security and prison management.
The jury ruled that there was insufficient training and knowledge of some prison policies, a failure to carry out and follow agreed actions regarding healthcare, and "inadequate interventions at times of greatest healthcare need".
Today, coroner Mr Osbourne passed his condolences to the family, who were not at the inquest, through their legal representatives.
He said: "The treatment that Aleksey received during the period that he was at Rye Hill was both appalling and at times unacceptable.
"I have no hesitation in adopting the words of Stephen Shaw from the Prison and Probation Ombudsman when he said it was 'shameful'.
"If there is a consolation to the family then one hopes that, as a result of the jury's verdict and the result from the Prison and Probation Ombudsman's report, this inquest will ensure that similar deaths in similar circumstances will not happen at Rye Hill or indeed any other prison."
The coroner said he did not feel the need to write any report or recommendations following the inquest, as changes had already been made at the prison.
He said: "I believe that GSL (which runs the prison) and those running Rye Hill will continue to maintain and audit the situation there."
The inquest heard that Baranovsky feared deportation back to the Ukraine, where he believed he would be killed.
During the inquest, Terry Divine, a "listener" at Rye Hill, said he had worked with prisoners and recognised self-harmers but Baranovsky was "not a scratcher" and wanted to die.
But Rev Edward Fowowe, chaplain manager at Rye Hill, said he did not think the Ukrainian meant to kill himself but had just gone too far.
He said that, when he visited Baranovsky in his blood-covered cell, the inmate told him he self-harmed for attention as he felt he was being neglected.
The inquest heard that a psychiatric assessment recommended after a meeting at the jail was not carried out as staff did not feel it was necessary and no detailed care plan for his long-term treatment was drawn up.
Several staff members told the hearing that Baranovsky repeatedly refused treatment and food, despite their efforts.
Liz Clay, security manager at the prison, told the inquest that, on one occasion, "quite a lot of blood" had been left in the cell for more than 12 hours before it was properly cleaned.
Chaplain Charles Sweeney said other prisoners were concerned about the blood in Baranovsky's cell.
He said he thought there was a "lack of care and compassion" towards the inmate.
Today, the jury ruled that the cause of death was anaemia due to chronic blood loss, and under-nutrition.
Baranovsky's death was one of three controversial deaths at the prison in a 15-month period.
In March 2005, Michael Bailey was found hanging in his cell in the segregation unit, and just a month later inmate Wayne Reid was stabbed to death in the jail.
The prison was heavily criticised by inspectors who said it was an "unsafe and an unstable environment, both for prisoners and staff".Reuse content