Latest news with #PrisonsOmbudsman
BBC News
4 days ago
- Health
- BBC News
Prisoner at HMP Bristol died after 'unsafe' nursing, report says
A prisoner who had a rare form of pneumonia died after "poor and unsafe" nursing caused delays in him being assessed and treated, a report Uzzell, 42, had been charged with violent offences and was on remand at HMP Bristol when he became unwell on Christmas Eve 2022. He died in hospital four days Prisons and Probation Ombudsman found Mr Uzzell reported coughing up blood but the agency nurse who assessed him did not record his observations or mention them during morning handover.A spokesperson for the prison service said it had since made "significant improvements" and taken action to ensure staff properly record decisions. Mr Uzzell was the seventh prisoner at Bristol to die since December 2019 and there have been a further seven deaths since, the report first became unwell in the early hours of 24 December 2022 and was assessed by Nurse Uzzell remained unwell and his symptoms got worse. At about 09:00 GMT another nurse reviewed him and found he needed to be assessed by a critical care team in also notified the prison's head of healthcare about Nurse A's failure to record his assessment or hand over Uzzell did not recover and at an inquest in June the coroner for Avon concluded he died from natural causes, adding the delay in hospital admission increased the speed and severity of the illness and accelerated his A's actions remain under investigation by the Nursing and Midwifery Council, the report adds. The report said Nurse A initially failed to engage with the ombudsman's investigation and maintained he had provided a statement to the prison's head of healthcare, who disputed a statement submitted to the clinical reviewer, Nurse A said Mr Uzzell was alert and said he advised him to contact prison healthcare if his symptoms report adds: "He also said that he had spoken about Mr Uzzell during the handover to healthcare day staff, but we found no evidence to corroborate this." The report recommends agency staff are "clinically competent" to be assigned to the role of lead emergency nurse and that improvements are made to the documentation of interactions and also said record keeping when dispensing medication should be improved, as Mr Uzzell was given over-the-counter painkillers three times from 19-20 December but the reason for this was not recorded. In 2023, a damning report into HMP Bristol said there were "chronic and intractable" problems, which led to HM Chief Inspector of Prisons Charlie Taylor describing it as "one of the most unsafe prisons in the country".A spokesperson for HM Prison Service said: "We accepted all of the ombudsman's recommendations and took action in 2023 to ensure staff properly record key decisions and preserve important documents after a death in custody."Since 2023, HMP Bristol has made significant improvements including boosting security, expanding support services, and improving rehabilitation to help reduce reoffending and make the prison safer."
Daily Record
28-07-2025
- Daily Record
Family pay tribute to 'kindest' dad after death in prison
Thomas Oleisky, 32, died four days after he was found unresponsive in his cell at HMP Wealstun in West Yorkshire. Tributes have been extended to a young father whose life was tragically cut short just four days after he was discovered unresponsive in his cell at a West Yorkshire prison. Thomas Oleisky, aged 32, passed away on September 11, 2022, following the harrowing discovery of him in a cell at HMP Wealstun, near Wetherby, with his family remembering him as the "kindest, strongest, bravest person". An investigation into his death by the Prisons Ombudsman revealed that Oleisky was serving a 27-month sentence for controlling and coercive behaviour, marking his first stint in custody. Initially placed in Doncaster jail, he was later transferred to Wealstun. Oleisky had a known history of struggles with alcohol and drugs, and upon his arrival at HMP Doncaster, he exhibited signs of alcohol withdrawal, according to staff reports. On July 5 and 6, Oleisky suffered attacks from fellow inmates, necessitating medical attention on both days. He confided in prison staff that his relationship with a woman linked to a gang might have instigated these violent encounters, reports the Manchester Evening News. Furthermore, on September 2, officers uncovered homemade hooch in his cell and determined that he was intoxicated. The Ombudsman has highlighted a series of troubling events leading up to the death of a prisoner, Oleisky, who had initiated suicide and self-harm prevention protocols (known as ACCT) on September 5, 2022, following an incident where he harmed himself. He expressed fears for his safety on B Wing due to debts owed to other inmates for hooch, prompting his transfer to the segregation unit upon request. However, just two days later, Oleisky was returned to B Wing when he struggled to cope in segregation and there were no alternative placements available. That same afternoon, a relative alerted the prison that Oleisky had phoned his father in what seemed like a farewell call, as he intended to take his own life. Following these incidents, the Ombudsman reported that Oleisky was moved to G Wing with increased surveillance, involving checks every fifteen minutes. Sadly, within an hour, he was discovered unresponsive. Despite being rushed to hospital, Oleisky did not recover consciousness and passed away four days later, as detailed by Yorkshire Live. The Ombudsman's report expresses concern over the decision to move Oleisky back to B Wing, which was the catalyst for his initial self-harm. The report criticises the decision-making process, stating: "I am concerned about the decision to move Mr Oleisky back to B Wing, the location that had triggered his initial act of self-harm. The decision appeared to have been taken unilaterally by a prison manager. "I consider that there should have been a multi disciplinary discussion about the best location for Mr Oleisky. While staff considered placing Mr Oleisky on constant supervision on 7 September, I am satisfied that the decision to increase observations to four an hour was reasonable in the circumstances. The investigation found that while staff held multidisciplinary ACCT reviews and set appropriate care plan actions, the care plan was not completed correctly which potentially led to confusion about whether actions had been completed or were still outstanding." A clinical reviewer concluded that Wealstun provided reasonable care for Oleisky's substance misuse and mental health issues, though she pointed out problems with record-keeping and sharing of information. The Ombudsman also highlighted a delay in activating the medical emergency code when Oleisky was found unresponsive, leading to a recommendation being made to the prison governor. The inquest in March delivered a narrative verdict stating: "Tom deliberately did the act that ended his own life but his probable intent cannot be ascertained. The causative issue was the decision at the ACCT Review on the September 7, 2022, not to remove items which could be used as a ligature." On the matter of confiscating personal items, the Ombudsman remarked: "We note that staff did not remove any items, such as shoelaces or clothing, from Mr Oleisky after he tied the dressing gown cord around his neck when he returned to B Wing. It is a difficult judgement call as it can be distressing to prisoners to have personal items removed and it should be reserved for prisoners at very high risk. "Staff told us that Mr Oleisky's mood calmed significantly during the final case review and apart from withholding razors, they did not consider that removal of any other items was necessary given the frequency of observations in place and the move to G Wing. We consider this was reasonable in the circumstances."
