Prison's gross failures contributed to death of inmate, inquest finds
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Version 2 of 4. A catastrophic series of failures contributed to the death of a prisoner, who died after setting fire to his cell, an inquest jury ruled. Robert Majchrzak, 30, died from smoke inhalation on 6 August 2013 at HMP Wealstun, near Wetherby in West Yorkshire. A jury at Leeds coroner’s court heard that he had set fire to his cell at the category C prison the evening before. Inmates reported a “strange, burning smell” and two patrolling prison officers also noted the smell but failed to patrol the second floor landing where Majchzak was held. Majchrzak, from Leeds, was serving 40 months for arson. The coroner called cells at the jail “fire traps”. Majchrzak, who had mental health problems and learning difficulties, had expressed suicidal thoughts but no protective measures were put in place. The jury heard that in the weeks leading up to the death, staff and inmates on the wing noticed Majchrzak’s mental health had deteriorated significantly and he became increasingly paranoid. They also heard that a prison “listener” had been called to give support to Majchrzak on 30 July and made his suicidal thoughts known to a prison officer. However, no suicide or self-harm protective measures were put in place. Two days before the fire, a prison officer noted that Majchrzak was “increasingly paranoid and erratic”, and the following day he was sent back early from the prison workshop due to his distress. He was still not placed on an at risk register, which the jury concluded was also a gross failure. Despite the significant amount of smoke produced by the cell fire, no alarm sounded. The jury heard evidence that one smoke detector was shared between six cells on three levels. The ventilation grill in the cell was obstructed due to being painted over but, in any event, the system would have not have provided sufficient early warning, the inquest was told. The prison’s fire safety adviser said he had not been aware of the fire detection problems. He admitted he was not aware of information updates, advising of the inadequacies of the system, circulated 10 years earlier by the National Offender Management Service and the Ministry of Justice. Both bodies had directed Wealstun and other jails not to rely solely on these systems, saying they were not fit for purpose. Plans were made to upgrade the system, but no interim safety measures were put in place. Four days before Majchrzak’s death, Crown fire inspectors wrote to Wealstun’s governor confirming that the prison still lacked effective interim measures. That notice was effectively ignored. In their narrative verdict, the jury concluded that Majchrzak died as a result of unintended consequences of his deliberate act, contributed to by the prison’s neglect. Seven gross failures were identified. After the verdict, the assistant coroner for West Yorkshire East, John Hobson, said that, in addition to making a range of recommendations, he would be writing to West Yorkshire police to urge a full review of the evidence heard in relation to potential breaches of fire safety orders. Zbigniew Majchrzak, Majchrzak’s uncle, said obtaining disclosure of the facts surrounding the death had been challenging and that if the family had not asked asked questions and pushed for answers, the circumstances would never have been made public. He said key documents relating to fire safety were only disclosed shortly before the inquest began. “In our view, we as a family should have been made aware of these findings much earlier. Now these gross failures have been highlighted, the family can now hopefully find some closure,” he said. Deborah Coles, the director of the charity Inquest, accused Wealstun prison of an alarming disregard for prisoner safety. She said it was equally shocking that prison officers failed to undertake proper night patrols even though a burning smell was detected, risking the safety of all prisoners. She said Majchrzak was a vulnerable prisoner whose mental health needs were not appropriately provided for. “This is the case for a large proportion of the prison population. The government must act to divert more people with mental health problems from custody, and for those who need to be imprisoned ensure that necessary support systems are in place,” she said. Rebecca Treece, the solicitor for Majchrzak’s family, said the jury’s findings indicated that at the time of his death, inmates at Wealstun were locked in cells the coroner called fire traps. “Robert was a vulnerable young man who fell victim to inadequate systems and slack practices within the prison. His family are keen to see evidence of improvements made in relation to all the failures identified by the jury,” she said. A prison service spokesperson said: “This is an appalling case and our thoughts are with Robert Majchrzak’s family and friends. “The safety and welfare of people within our custody is our top priority but we recognise that there were significant failings in the care of Mr Majchrzak. “We have already taken action and accepted all the recommendations following the PPO [prisons and probation ombudsman] investigation. We will now carefully consider lessons learnt from the inquest findings to help ensure such incidents are not repeated.” |