HMP Wandsworth staff did not take “any meaningful” steps to prevent a prisoner taking his own life, a watchdog has found.
Aleksandras Maslennikovas, 47, was found unresponsive in his cell on July 17, 2023.
A new Prisons and Probation Ombudsman report found staff at the prison closed suicide and self-harm monitoring protocols, known as ACCT for Mr Maslennikovas – just 16 hours after opening them and five days before he died.
Mr Maslennikovas was remanded to HMP Wandsworth on June 14, 2022, after an arrest warrant for armed robbery was issued in his home country of Lithuania.
Staff began ACCT monitoring for Mr Maslennikovas after he self-harmed on July 12. There was no evidence staff used formal interpreting services for him, the report said, despite him speaking little English.
Mr Maslennikovas said he had harmed himself because he was under threat from other Lithuanian prisoners on the wing.
Staff stopped ACCT monitoring of Mr Maslennikovas the following morning, just 16 hours later, as he said he would not self-harm again and was no longer under threat.
The ombudsman said it was not clear if staff had taken any steps to understand the nature of the threat or how they had resolved it so quickly, or if they had taken into account any of his known risk factors.
He had multiple risk factors for suicide and self-harm, according to the report, including being a foreign national prisoner, awaiting extradition, a history of mental ill-health, self-harm and substance misuse and no contact with his family.
The watchdog said healthcare staff did not attend Mr Maslennikovas’ ACCT review and did not appear to have assessed his mental health since his self-harm.
Mr Maslennikovas displayed more unusual behaviour on July 14 and 15, burning paper and smashing up his cell, and asked to be moved to another wing.
The ombudsman found no evidence staff considered whether ACCT monitoring should have been reopened for him.
He was moved to another wing on July 15, which was described at the time as volatile. Prisoners reported to staff that they did not feel safe and wanted to be moved.
Mr Maslennikovas was found unresponsive in his cell on the morning of July 17. He was pronounced dead by paramedics at 9.37am.
The report said: “While we have not seen any particular evidence to suggest that he was in crisis in the hours before his death, nor have we seen any particular evidence that staff had taken steps to properly assess his risk at any time before that.
“We do not consider that staff took steps to support Mr Maslennikovas or prevent his death in any meaningful way.”
The report added Mr Maslennikovas was the fourteenth prisoner at HMP Wandsworth to take his life since January 2020. Up to the end of November 2024, five more prisoners had taken their life.
The watchdog said the prison had been identified as needing extra support due to a high number of suicides, the high-profile escape of Daniel Khalife and an urgent notice about extremely poor conditions in May 2024.
Inspectors at the time found self-harm rates were high and rising, and around 40 per cent of cell bells were not answered within five minutes. They said many prisoners were clearly in distress without appropriate support and there were weaknesses in the ACCT case management process.
The ombudsman said the prison had recognised failures in the management of Mr Maslennikovas and had started work to resolve the issue.
The Prison Service and Oxleas NHS Foundation Trust, which provides healthcare services at the prison, have been contacted for comment.
A Prison Service spokesperson: “HMP Wandsworth has improved care for vulnerable prisoners following this case, including introducing better support for new prisoners and ensuring staff receive a daily list of those at risk so they can be properly supervised.”
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