- Watchdog: Unspecified organization monitoring prisons.
- Prison: HMP Wandsworth, London facility.
- Issue: Failures to protect suicidal prisoner.
- Reaction: Watchdog expressed shock over lapses.
- Context: Highlights ongoing safety concerns in custody.
On May 12, 2021, Sebastian Lucas, 34, committed suicide two days into his incarceration at the Wandsworth prison after being sectioned for allegedly attacking a medical staff.
According to a recent Prisons and Probation Ombudsman report, personnel did not properly assess Mr. Lucas’ risk or ensure his safety. It claimed that a stronger feeling of urgency and an improved risk assessment could have prevented his death.
In September of last year, an inquest determined that Mr. Lucas’s death was caused by suicide that was exacerbated by negligence. On May 10, 2021, Mr. Lucas was remanded in custody at HMP Wandsworth after reportedly attacking a hospital worker while sectioned because he was contemplating suicide.
He showed there with documentation that stated he had been under continual court supervision and had threatened to commit suicide. In spite of this, the receptionist did not start the ACCT (suicide and self-harm protocols) for him.
The Ombudsman expressed shock that the officer was unaware of its repeated cautions that staff members too frequently evaluate a prisoner’s risk based just on their appearance and words, failing to consider their risk indicators. It stated that the officer ought to have opened an ACCT for Mr. Lucas after taking into account the information at her disposal.
The watchdog expressed shock at the fact that a nurse who evaluated Mr. Lucas later neglected to review the documentation he brought with him in order to determine his level of risk. He informed her that he intended to commit suicide.
After this examination, the nurse took almost an hour to initiate an ACCT for him, so when an officer discovered suspected drugs within him, he was unable to determine if their confiscation may raise his risk of suicide.
After the ACCT was opened, a manager took six hours to speak with Mr. Lucas and finish an action plan, even though the regulation stated that this had to be done within an hour.
On May 12, when cops discovered Mr. Lucas unconscious in his cell, control room personnel mistakenly informed the 999 operator that he was breathing. The Ombudsman stated that although this had no bearing on Mr. Lucas’s outcome, it might have a significant impact in other situations. Within two days of his arrival at the prison, paramedics declared him dead.
The watchdog determined that no one in the institution had accurately or appropriately assessed Mr. Lucas’ level of risk.
The Ombudsman claimed that Mr. Lucas’ action plan, which solely suggested that he required a television, did not sufficiently represent his requirements or plans to lessen his distress.
Additionally, because officers did not assume responsibility for finishing ACCT observations following handover, staff failed to complete them between 11.42 a.m. and 2.25 p.m. on May 12, when Mr. Lucas was found unresponsive.
“Very concerning that the prison failed to assess his risk adequately or keep him safe” was how the report put it.
It said:
“Key information was not sufficiently communicated or considered. In addition, the clinical reviewer concluded that Mr Lucas’ mental healthcare in relation to his risk of suicide was not adequate or equivalent to that he could have expected to receive in the community.
Mr Lucas had been treated as a high risk to himself in hospital, police custody and court custody and was being dealt with urgently. I am dismayed that once he arrived at Wandsworth the need for the same level of urgency and for acute care was not recognised. We cannot say whether better risk assessment and a greater sense of urgency would have saved his life, but it may have done.”
In just over six months, there have been seven suicides in HMP Wandsworth; Mr. Lucas’s death was the fourth. The Ombudsman is still looking into the three suicides that occurred after his.
What were the watchdogs’ main criticisms of Wandsworth procedures?
The incarcerations and Probation Ombudsman( PPO) outlined ruinous failures in HMP Wandsworth’s procedures for guarding suicidal internee Rajwinder Singh, who failed by self-murder 11 days after appearance in June 2023.
Staff neglected core ACCT( Assessment, Care in Custody and Teamwork) protocols by failing to conduct original threat assessments despite Singh’s proved tone- detriment history, depression, and pregabalin tradition risking pullout suicidality. No devoted case fellow was assigned, hourly compliances were falsified( CCTV showed no checks).
Post-self-harm incidents including ligature use and setting fire to his hair/ mop demanded four needed reassessments, with pregabalin taper unmonitored despite warnings. Singh’s woman’s posted safety enterprises were ignored, and exigency protocols collapsed amid 40 unanswered cell bells captivity-wide.
