Wandsworth (Parliament Politics Magazine) – A watchdog has ruled that a prisoner at HMP Wandsworth would still be alive today had it not been for a series of failings at the jail.
Staff members frequently failed to assist Rajwinder Singh, 36, from Wandsworth who committed suicide just 11 days after being admitted to the South London prison in June 2023, according to a damning inquiry.
When his wife called to inquire about his well-being the day he passed away, staff members were discovered to have fabricated records, disregarded his call bell, and failed to check on him.
The institution “made critical and repeated failings in their duty of care to Mr. Singh,” according to a damning assessment by the Prisons and Probation Ombudsman. According to the report, his treatment revealed that the prison’s implementation of the ACCT (a suicide and self-harm procedure) was “little more than shambolic.”
Ombudsman Adrian Usher wrote:
“The failures in this case were voluminous and diverse. There were multiple opportunities for meaningful interventions within Mr Singh’s care that would have led to a different outcome, that were repeatedly missed.
I do not make the following statement lightly, but I consider that had Mr Singh been sent to a different prison in 2023, not in such a state of crisis, he would almost certainly still be alive today.”
On June 9, 2023, Mr. Singh was sentenced to four years and fourteen days in jail for the acquisition, use, and possession of criminal goods. He was then brought to HMP Wandsworth.
He took medicine for his depression, fibromyalgia, asthma, and alcoholism.
According to the report, Mr. Singh’s risk of suicide and self-harm was not appropriately evaluated upon his arrival at the prison, even though his notes indicated that he had tried suicide and self-harmed within the previous six months.
It said that starting on June 12, he was “extremely poorly managed” under ACCT. He was never assigned a case coordinator and was not checked as frequently as he should have been every hour, frequently with lengthy intervals between documented checks.
According to the findings, personnel ought to have thought about whether he required round-the-clock supervision.
On June 17, a nurse began lowering Mr. Singh’s pregabalin dosage with the goal of removing it entirely after seven days because he had claimed to have epilepsy, but this could not be verified.
It was unknown why he took the drug, which is used to treat anxiety and nerve pain in addition to epilepsy. The reduction in his prescription was not disclosed to him.
According to the study, personnel should have taken into account how Mr. Singh’s mental health was impacted by lowering his pregabalin dosage because quitting it can result in anxiety and suicidal thoughts and actions.
He was put on a waiting list to see a psychiatrist, and no plans were made to check him again after the watchdog discovered that Mr. Singh’s urgent mental health examination later that day had failed to identify his current dangers.
On the same day, his wife called the prison to voice concerns about him, but there was no proof that anyone had checked on him.
When Mr. Singh rang his call bell at 8:36 p.m. that night, staff did not answer, which the study stated was a “serious missed opportunity” to save his life. At 9:06 p.m., officers discovered him unconscious in his cell. After being brought to the hospital, he passed away on June 25.
Mr Usher said:
“The challenges faced at Wandsworth are tragically demonstrated by the inadequacies in Mr Singh’s care. There were stark and repeated failings to adequately assess and manage his risk to himself and support him appropriately.
The ACCT process was conducted more frequently in breach of policy than in its observance. Staff also falsified records and failed to answer Mr Singh’s cell bell which he had pressed 30 minutes before he was found [unconscious].
Healthcare staff failed to adequately assess or support his deteriorating mental health. Changes in his medication were not communicated directly to Mr Singh and he did not always receive his prescribed medication. This worsened his mental health and increased his risk to himself.
I remain extremely concerned about prisoner care at Wandsworth and I urge HMPPS [HM Prison and Probation Service] to consider how they can support meaningful improvements before another prisoner takes their own life.
Wandsworth did alarmingly little to appropriately care for Mr Singh, nor did they recognise or attempt to mitigate his obviously increasing risk.”
A Prison Service spokesperson said:
“Our thoughts remain with those who knew Rajwinder Singh. We have accepted and actioned the Prisons and Probation Ombudsman’s recommendation.
This includes updating suicide and self-harm prevention procedures to ensure we can better identify prisoners at risk.”
What specific failings did the watchdog identify at HMP Wandsworth?
Staff absence often reached 50%, and operational staff were mostly inexperienced, which significantly undermined the prison’s capacity to operate both safely and effectively. About 80% of prisoners shared cells intended for one person, and many were confined for more than 22 hours a day in those conditions. Most also had floors that had been damaged, broken windows, leaking fixtures, and no privacy for toilet use.
There have been increases in violence (including serious assaults) and rising rates of self-harm; there were 10 self-inflicted deaths in the last period of inspection.
There were constant instances of CCTV cameras defunct (for periods that exceeded a year) and on audit there were 81 security failures identified. Staff were routinely unable to account for the number of prisoners, and where they were, in the daytime.