Inmate’s Death Follows Isolation and Mental Health History, Inquest Hears

An inquest has revealed that an inmate discovered deceased in his cell was “isolated” and possessed a history of depression and suicide. Rolandas Karbauskas, aged 49, had been transferred to HMP Lowdham Grange from HMP Lincoln on 20 March 2023, and his body was found by another prisoner five days subsequent to his arrival. His death marked the third instance of an inmate being found deceased at the Category B facility within a single month, following the deaths of Anthony Binfield and David Richards in the preceding weeks. During an inquest held at Nottingham Coroner’s Court on Thursday, a jury was informed that no official measures were implemented to manage Karbauskas’s mental health concerns. Karbauskas, who was a Lithuanian national, was initially remanded into custody at HMP Lincoln on 19 March 2022, at which time his records indicated a warning for suicide and self-harm. Six months subsequent to this, it was revealed that a mental health referral initiated for him at that juncture had never been acted upon. The inquest jury learned that the inmate “spoke very little English” and consequently needed an interpreter for his appointments and evaluations. It was also noted that throughout his period of custody since March 2019, the ACCT process—an acronym for assessment, care in custody and teamwork, designed to assist prisoners at risk of self-harm or suicide—was never put into practice. Upon his arrival at HMP Lowdham Grange on 20 March 2023, his reception healthcare screening was conducted by assistant practitioner Angela Bevis rather than a nurse, a situation attributed to “staffing levels”. Ms. Bevis informed the jury that she lacked formal or specific training for performing such a screening. The facility had transitioned from private providers Serco to Sodexo in February 2023, and evidence presented to the jury throughout the inquest indicated that it had been understaffed at the time of the inmates’ fatalities. Ms. Bevis testified that she was unaware of Karbauskas’s history of mental health problems, explaining that she had not reviewed his records from HMP Lincoln beyond the preceding six months. Nevertheless, the practitioner stated she initiated an “urgent referral” to a mental health team after the inmate “stated he had always suffered with mental health,” with the assistance of another Lithuanian prisoner who translated their discussion. Ms. Bevis further commented that she “didn’t want him to feel more isolated than he probably already felt.” This referral, which the court was told should have been processed within 48 hours, was not completed due to the absence of an arranged interpreter, notwithstanding explicit notes within the system where the referral was recorded. Additionally, concerns regarding Karbauskas were voiced by Anthony Davies, the prisoner who later found him deceased. Mr. Davies, who resided on the same E wing, served as a “wing buddy” at that period, a role that entailed providing emotional assistance to fellow inmates. The court was informed that Karbauskas was last observed alive at 16:50 on 24 March, prior to Mr. Davies discovering him the subsequent morning at 10:30. Mr. Davies stated that he learned Karbauskas was Lithuanian soon after his arrival and wished to assist him, having “picked up” some Lithuanian words or phrases. Mr. Davies remarked that the inmate appeared as though he “hadn’t been looked after” and observed that he had not eaten the day preceding his death. “There was something definitely not right with that chap, he needed help,” Mr. Davies commented. Footage presented to the jury depicted Karbauskas distributing food items from his cell within the 24-hour period before his death, an action Mr. Davies identified as a “red flag” based on his prior training for the wing buddy position. The jury was informed that Mr. Davies conveyed his apprehension about the new inmate to a prison officer, leading to attempts to provide him with food and engage in communication. A Quaker chaplain at the prison also endeavored to assist the inmate, recording in a statement read to the jury that Karbauskas “spoke no English at all.” The chaplain stated that despite attempts to locate an interpreter, no one who spoke Lithuanian could be found during her interaction with him. She remarked: “He was a very thin man and I was concerned about him.” The jury was told that a Sodexo prison officer, who had been seconded to HMP Lowdham from Peterborough at that time, was likely the sole individual to have engaged in a complete conversation with Karbauskas during his five-day stay at the prison. The officer recounted being requested to translate for Karbauskas during a prison induction, where she remembered him mentioning that he experienced “depression and anxiety.” In the course of that discussion, the officer stated that the inmate was informed a referral would be initiated to address these concerns. She was unaware of any other referrals due to insufficient access to prison records, an issue she noted officers had previously brought to Sodexo’s attention. She commented, “I’m possibly the only person that had had a full conversation with him [at the prison].” The jury was also informed that he had not received any phone calls or visitors for a “considerable amount of time.” The inquest remains ongoing.