A prisoner “would almost certainly still be alive today” if he had not been sent to crisis-hit HMP Wandsworth, a watchdog has ruled.
A damning investigation found staff repeatedly missed opportunities to help Rajwinder Singh, 36, who took his own life just 11 days after arriving at the South London prison in June 2023.
Staff were found to have falsified records, ignored his call bell and did not check on him when his wife phoned with concerns for his welfare the same day he died.
A scathing Prisons and Probation Ombudsman report said the prison “made critical and repeated failings in their duty of care to Mr Singh”. It said his care indicated the prison’s delivery of suicide and self-harm protocols, known as ACCT, 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.”
Mr Singh was taken to HMP Wandsworth after being sentenced to four years and 14 days in prison for the acquisition, use and possession of criminal property on June 9, 2023.
He had fibromyalgia, asthma, alcohol problems and depression, for which he took medication.
The report found Mr Singh’s risk of suicide and self-harm was not properly assessed when he arrived at the prison, despite his notes warning he had self-harmed and attempted suicide in the last six months.
It said he was “extremely poorly managed” under ACCT from June 12. He was not checked every hour as he should have been, often with long gaps between recorded checks, and he was never given a case coordinator.
Staff failed on four occasions to immediately review Mr Singh’s risk when he self-harmed from June 15 to 19, despite this escalating in seriousness to tying a ligature around his neck and setting his hair on fire.
The report said staff should have considered whether he needed to be constantly supervised.
A nurse started reducing Mr Singh’s dose of pregabalin on June 17, with a view to stopping it completely after seven days, as he had reported having epilepsy and this could not be confirmed.
While the medication is used to treat epilepsy, it is also used for nerve pain and anxiety, and it was unclear why he took it. He was not told his prescription was being reduced.
The report said staff should have considered how reducing Mr Singh’s pregabalin dose affected his mental health, as stopping it can cause anxiety and suicidal thoughts and behaviour.
On June 18, he told his wife he did not know why “they had stopped his medication” and he needed it to help with his pain. He also did not always receive medication for his mental health due to short staffing, which he said had caused it to deteriorate.
The frequency of Mr Singh’s ACCT checks was only increased to twice an hour after he set fire to a mop in his cell around midnight on June 20, when he also expressed wanting to take his own life. This came just hours after he had set fire to his own hair.
The watchdog found an urgent mental health assessment of Mr Singh later that day failed to identify his current risks, while he was placed on a waiting list to see a psychiatrist and no plans were made to review him again.
His wife phoned the prison to raise concerns about him on the same day, but there was no evidence anyone completed a welfare check on him.
Staff did not respond when Mr Singh rang his call bell at 8.36pm that evening, which the report said was a “serious missed opportunity” to save his life. Officers found him unresponsive in his cell at 9.06pm. He was taken to hospital but died on June 25.
The investigation revealed staff had falsified records, as CCTV from 5pm on June 20 showed two checks that were documented had not actually been carried out.
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.”
When life is difficult, Samaritans are here – day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit samaritans.org to find your nearest branch.
