A prisoner who faced deportation to Lithuania was segregated for 52 days with no care plan before his death.
Staff at HMP The Mount made “insufficient efforts to establish any understanding” with Karolis Baltrunas before he took his own life on August 27, 2020, the Prisons and Probation Ombudsman found.
Ombudsman Adrian Usher was left “extremely shocked” with elements of the care which Mr Baltrunas received, he wrote in a report.
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The document, released in April after an inquest earlier in 2024, sets out Baltrunas arrived at HMP Bedford in May 2019 charged with conspiracy to steal motor vehicles.
He was moved to HMP The Mount in Bovingdon when courts sentenced him to three years and four months in prison.
Baltrunas refused to move to an immigration centre on July 3, 2020, the report adds, four days before he was put into a segregation unit “for threatening two officers”.
The report reads: “On August 24, Mr Baltrunas damaged his cell, and he was noted to be aggressive and non-compliant.
“A planned intervention was arranged to move him to a new cell.
“Staff went to his cell to tell him about the move, and he was asked if he would comply.
“He said that he would, and he was warned that he would be restrained if he resisted.
“Mr Baltrunas remained compliant.”
Body-worn video footage from August 24 showed Baltrunas had cuts to parts of his body.
A nurse told a debrief group that the cuts “were self-inflicted”, and one needed cleaning, glueing and Steri-Strips, the report continued.
“On August 25, staff noted that Mr Baltrunas’ planned deportation on the previous day had been cancelled and that Mr Baltrunas had ‘been acting very strange’,” the report reads.
Officers found Baltrunas dead in his cell at around 8am on August 27.
Mr Usher concluded the nurse who looked at Baltrunas’ injuries on August 24 “did not start Assessment, Care in Custody and Teamwork (ACCT) procedures because Mr Baltrunas had no history of self-harm”.
He wrote: “We are very concerned that none of the prison staff thought it necessary to begin ACCT procedures.
“All the staff involved in the intervention would have seen the injuries, and they all attended the debriefing meeting when Nurse B said the injuries were self-inflicted.
“Nor do we understand Nurse B’s rationale in deciding not to open an ACCT.
“Whether or not Mr Baltrunas had self-harmed in the past, he had self-harmed on this occasion, and there is more to the ACCT procedures than being checked regularly: they are also about trying to identify the cause of the prisoner’s distress and putting support in place.”
Mr Usher added: “From the records provided, it would seem that poor and uncooperative behaviour became the established pattern for him.
“We also note that he was clearly resistant to the plans for his deportation, so we can understand why the prison considered that the most pragmatic way forward was to keep him in the Care and Separation Unit until he was remanded into the care of immigration staff, which was anticipated to take place on August 24.
“However, we are concerned that insufficient efforts were made to establish an understanding of Mr Baltrunas and the concerns he might have had about his deportation.”
He said his team was “very concerned that when Mr Baltrunas passed 30 days in segregation, no care plan was created for him to support his mental health”.
Mr Usher said prison leaders should allocate a designated officer to each prisoner in segregation and make sure this officer “has purposeful dialogue each day with his or her allocated prisoners”, recording a “quality” log for each prisoner daily.
He also said senior leaders should start ACCT processes “following all acts of self-harm”, and “ensure that staff use a translation service when discussing sensitive or complex matters with prisoners who do not speak English well”.
A Ministry of Justice spokesperson told the Local Democracy Reporting Service: “Our thoughts remain with Mr Baltrunas’ friends and family.
“We’ve noted the ombudsman’s findings and have taken action to improve the mental health support provided to vulnerable prisoners.
“Segregation is an absolute last resort for those deemed a danger to themselves or others.”
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