A Prisons and Probation Ombudsman report has found that staff at HMP Wandsworth took no meaningful steps to prevent the suicide of prisoner Aleksandras Maslennikovas, 47, who died in his cell on July 17, 2023.
Failures in monitoring and risk assessment
The report revealed that staff closed suicide and self-harm monitoring protocols, known as ACCT, for Mr Maslennikovas just 16 hours after opening them and five days before his death. He had been remanded to the South London prison on June 14, 2022, following an arrest warrant for armed robbery issued in his home country of Lithuania.
Staff began ACCT monitoring after Mr Maslennikovas self-harmed on July 12, 2023. He said he had harmed himself because he was under threat from other Lithuanian prisoners on the wing. However, there was no evidence that staff used formal interpreting services for him, despite his limited English.
The ombudsman stated that it was not clear staff had taken any steps to understand the nature of the threat or how he had resolved it so quickly, nor had they considered his known risk factors. These included being a foreign national prisoner, awaiting extradition, a history of mental ill-health, self-harm, substance misuse, and no contact with his family.
Healthcare and subsequent incidents
Healthcare staff did not attend Mr Maslennikovas' ACCT review and did not appear to have assessed his mental health since his self-harm. On July 14 and 15, he displayed unusual behaviour, burning paper and smashing up his cell, and asked to be moved to another wing. The ombudsman found no evidence that staff considered reopening ACCT monitoring.
He was moved to another wing on July 15, which was described as volatile. Prisoners reported feeling unsafe and wanting to be moved. Mr Maslennikovas was found unresponsive in his cell on the morning of July 17 and was pronounced dead by paramedics at 9.37am.
Ombudsman's findings and wider context
The report stated: "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."
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 died by suicide. The prison had been identified as needing extra support due to the high number of suicides, the high-profile escape of Daniel Khalife, and an urgent notice about poor conditions in May 2024.
Inspectors at that time found self-harm rates were high and rising, with around 40 per cent of cell bells not answered within five minutes. Many prisoners were in distress without appropriate support, and there were weaknesses in the ACCT case management process.
Response and improvements
The ombudsman noted that the prison had recognised failures in the management of Mr Maslennikovas and had started work to resolve the issue. A Prison Service spokesperson said: "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."
Oxleas NHS Foundation Trust, which provides healthcare services at the prison, has been contacted for comment.
