A jury at the inquest into the death of 66-year-old Wadid Barsoum, who was killed by his cellmate whilst on remand at HMP Wandsworth has concluded he was unlawfully killed.
The conclusion comes after an eight day inquest heard by Westminster Coroner, Dr Shirley Radcliffe, sitting in the High Court. The jury noted in their conclusion a failure of the prison’s in-reach team to read a report by a consultant psychiatrist containing useful information about the cellmate’s mental health. They were directed not to make any further criticisms of the prison or healthcare staff by the coroner however, they did make a request to include comments relating to significant pressure on resources at Wandsworth and an absence of adequate communication systems but the coroner refused.
On 4 May 2015, Taras Nykolyn attacked Mr Barsoum with their shared television set and as a result, Mr Barsoum died from severe head injuries. Mr Nykolyn was later convicted of manslaughter on the grounds of diminished responsibility.
Mr Barsoum was sharing a cell with Mr Nykolyn, who was being held at Wandsworth after committing a violent and unprovoked assault on an unarmed man on Wimbledon Common.
Despite this, in his cell sharing risk assessment he was deemed suitable to share a cell with another inmate. Over the following months, he was referred to the mental health in-reach team a number of times over concerns about bizarre behaviour and the possibility he was hearing voices. He also received disciplinary action as a result of fighting with a cellmate and smashing up his cell.
Two consultant forensic psychiatrists instructed by Mr Nykolyn’s defence solicitor had determined that Mr Nykolyn was acutely psychotic at the time of the offence on Wimbledon Common, that he may have a chronic underlying psychotic condition, and that his risk level was linked to his mental health. In January 2015, psychiatrists recommended that he be sent to hospital for his mental health to be monitored and assessed.
This did not take place and instead Mr Nykolyn was kept on the wing, being seen intermittently by a psychiatric nurse who did not read the psychiatric report and was not aware of the nature of his initial offence.
He was discharged from the mental health caseload on 26 February 2015, despite the fact that on the same day he was transferred to the segregation unit following an incident where he was described by a prison officer as not seeming to recognise him.
Mr Nykolyn was referred to in-reach again following concerns that he was hearing voices. He was seen for around 10-15 minutes by a consultant forensic psychiatrist who did not review the psychiatric reports available on his medical records and did not use an interpreter. He was discharged again a few weeks later.
Mr Nykolyn continued to show signs of deteriorating mental health and on 3 May, the day before the attack, he was acting aggressively, holding his head and repeating random words to prison staff. The inquest heard from consultant psychiatrist, Dr Baker, who said that according to the symptoms described, there was a strong possibility that they were indicative of a further psychotic episode. Mr Nykolyn was prescribed paracetamol by nursing staff.
In the early hours of 4 May 2015, Mr Nykylon killed Mr Barsoum. When asked why he committed the offence he responded “I looked in the mirror”.
Whilst the jury were not permitted to further criticise the prison or healthcare services in their conclusion, they indicated that they wanted to make the following findings about the circumstances of Mr Barsoum’s death:
- Restrictions in the Mental Health Act meant the care team were unable to transfer Mr Nykolyn to an external psychiatric unit more capable of carrying out the assessment suggested by the forensic consultant psychiatrist.
- There was significant pressure on available resources which led to a shortage of mental health staff, a heavy workload, a limited number of beds, limited mental health provision at weekends and limited interpreting services.
- There was an absence of common systems or procedures to ensure sharing of all information relating to the alleged offence which may be potentially relevant to inmates’ health and suitability to share a cell. This information was not communicated or readily available to prison officers or mental health staff at Wandsworth.
Claire Brigham, civil liberties solicitor at Hodge Jones & Allen represented Mr Barsoum’s family at the inquest. She says: “Wadid was a much-loved man and his family are devastated by what has happened. Although the coroner directed the jury not to make causative findings against the prison and the healthcare team, it is some comfort to the family to know that the jury did wish to raise the failure to transfer Mr Nykolyn for proper assessment of his mental health, the lack of common systems making sure police, prison and healthcare staff are aware of all relevant information about the initial offence where this is relevant to risk, and the significant pressures on available resources affecting mental healthcare in prisons.
“The family however, remain very concerned that the psychiatric nurse and the consultant psychiatrist responsible for Mr Nykolyn’s care in Wandsworth had not reviewed key information about Mr Nykolyn’s mental health and the risk he posed to others, and that neither agreed in questioning that they ought to have acted differently.”
The inquest concluded on 4 May 2017.
Notes for Editors
Hodge Jones and Allen
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