A schizophrenic inmate was never seen by a psychiatrist during his time at a South London prison before taking his own life.
A coroner has found failings in the care provided to Patryk Gladysz, 27, at HMP Wandsworth before he died on January 19, 2024.
In a new Prevention of Future Deaths report, Priya Malhotra, Assistant Coroner for Inner West London, raised concerns about understaffing and a lack of communication between departments at the category B men’s prison. She said Mr Gladysz was never given a key worker for one-to-one support, although this should be provided to all prisoners at HMP Wandsworth, nor was he seen by a psychiatrist.
Mr Gladysz, who had schizophrenia, arrived at HMP Wandsworth on April 17, 2023, awaiting extradition to Poland. Staff noted he needed an interpreter as he had limited English, but this was inconsistently recorded in later notes. He claimed asylum on April 26, 2023, preventing his extradition. He was under the care of the prison’s mental health in-reach team, provided by Oxleas NHS Foundation Trust.
The report said staff assessed Mr Gladysz around six months late, between October 20 and 27, 2023, when this should have been completed in April – within five days of his case being given to the mental health in-reach team. An official interpreter was not used for the assessments.
While Mr Gladysz usually received a fortnightly antipsychotic depot injection – a slow release form of injection – this was missed on November 23, 2023. He received his next injection five weeks later on December 14, and on the same day he first reported hearing voices.
There was also no entry in Mr Gladysz’s notes confirming any “meaningful interaction” with him, the report said, from May 22, 2023, until his death, although there was inconsistent knowledge among healthcare staff over whether they had access to this system.
Mr Gladysz was found unresponsive in his cell on January 5, 2024, and died in hospital on January 19.
An inquest into Mr Gladysz’s death, which concluded on July 15, 2025, heard the mental health in-reach team was understaffed at the time, which impacted the delivery of assessments. Staff who administered his injection did not know he had previously tried to take his own life outside of prison. Senior officers also showed a lack of awareness of policy concerning heightened risk to the mental health of foreign prisoners.
The inquest found staff did not carry out an in-depth psychological assessment of Mr Gladsyz, which was among factors likely to have possibly contributed, in a more than minimal way, to his death. The other factors were low staffing levels at the prison, lack of clear communication between departments, insufficient knowledge of his history and inconsistent familiarity with policies and procedures.
Ms Malhotra highlighted these factors as concerns in the report, warning that action should be taken to prevent future deaths.
A Ministry of Justice spokesperson said: “We will carefully consider the coroner’s findings and will respond to the report in due course.”
Oxleas NHS Foundation Trust has been contacted for comment.
You don’t have to suffer in silence if you’re struggling with your mental health. Here are some groups you can contact when you need help.
Samaritans: Phone 116 123, 24 hours a day, or email [email protected] in confidence
Childline: Phone 0800 1111. Calls are free and won’t show up on your bill
PAPYRUS: For teens and young adults. Phone 0800 068 4141
Depression Alliance: The charity offers useful resources for people struggling.
Students Against Depression: For students who are depressed, have low mood, or are suicidal.
Campaign Against Living Miserably (CALM): Phone 0800 58 58 58. For young men who are feeling unhappy.
James’ Place: Offering life-saving treatment to suicidal men in London and surrounding area.
For information on your local NHS urgent mental health helpline, visit here
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