Before Assistant Coroner Priya Malhotra
Inner West London Coroners Court
7 – 15 July 2025
Patryk Gladysz, a 27 year old Polish national, died two weeks after ligaturing whilst on remand at HMP Wandsworth on 19 January 2024. Now an inquest has found that failures in mental health care and communication likely contributed to Patryk’s death.
At the time of his death, Patryk was the eighth foreign national to die a self-inflicted death at the prison since 2021. HMP Wandsworth has also had the second highest number of self-inflicted deaths of all prisons in England and Wales since 2020, with 20 people having died by self-inflicted means.
Patryk loved to cook and laugh and was always willing to help. He liked games and mind puzzles and was interested in the ancient world.
Patryk had a diagnosis of schizophrenia and a history of suicide attempts in the community. He was under the care of community mental health services at the time of his arrest.
On 17 April 2023, Patryk was remanded to Wandsworth prison awaiting extradition to Poland. This was his first time in prison in the UK, and he spoke limited English. Despite this, prison and healthcare staff did not use formal interpreting services to communicate with him. Patryk became invisible in prison, demonstrated by the fact that there were no NOMIS case- notes on his record for 227 days and 147 consecutive days.
On 5 January 2024, an officer found Patryk ligatured in his cell. She called for assistance and called a medical emergency ‘code blue’. Staff began CPR until paramedics arrived. Patryk was taken to St George’s Hospital where he died on 19 January. Patryk was found to have self-harm marks on his thighs.
Evidence heard at the inquest was that Patryk developed further symptoms associated with his schizophrenia such as hearing voices but yet no steps were taken to address this or refer Patryk for a psychiatric assessment despite showing clear signs of deterioration.
Now an inquest jury has found that Patryk died having hung himself from a ligature, his intentions in doing so remain unknown. The jury also found that the following are likely to have possibly contributed in more than a minimal way to Patryk’s death:
- There was no in-depth psychological assessment of Patryk
- There were low staffing levels in the prison and in-reach healthcare teams
- There was a lack of clear interdepartmental communications
- There was a lack of knowledge of Patryk’s history and personal circumstances and inconsistent familiarity of related policies and procedures.
ENDS
NOTES TO EDITORS
The family is represented by INQUEST Lawyers Group members Sarah Kellas and Aisha Bailey of Birnberg Peirce and Paul Clark of Garden Court Chambers. They are supported by INQUEST Caseworker Jordan Ferdinand-Sargeant.
Other Interested persons represented are HMP Wandsworth, the Ministry of Justice and Oxleas NHS Trust.
Relevant background information
On 9 May 2024, Her Majesty’s Inspectorate of Prisons (HMIP) issued an urgent notification for HMP Wandsworth following an unannounced inspection and concerns including the high rates of self-harm and number of self-inflicted deaths. It also noted that around half of the population were foreign nationals and services had not been designed with this in mind.
In May 2025, HMIP published an Independent Review on Progress on the prison. It found that the rates of violence and self-harm had both reduced.
However, former Wandsworth prisoners and relatives of current prisoners who spoke at the recent open meeting disputed the claims of improvement, saying that conditions inside the jail remain dire.
In 2022, INQUEST published a report on the deaths of racialised people in prison and the role of racism in the preventable and premature deaths of 22 racialised people in prison.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Patryk Gladysz
CONTENT WARNING: Please read with care as this page may involve information on death, suicide, mental illness, disability, state neglect, and police and prison violence that some people may find upsetting. If you need support, please visit our support page.
Before Assistant Coroner Priya Malhotra
Inner West London Coroners Court
7 – 15 July 2025
Patryk Gladysz, a 27 year old Polish national, died two weeks after ligaturing whilst on remand at HMP Wandsworth on 19 January 2024. Now an inquest has found that failures in mental health care and communication likely contributed to Patryk’s death.
At the time of his death, Patryk was the eighth foreign national to die a self-inflicted death at the prison since 2021. HMP Wandsworth has also had the second highest number of self-inflicted deaths of all prisons in England and Wales since 2020, with 20 people having died by self-inflicted means.
Patryk loved to cook and laugh and was always willing to help. He liked games and mind puzzles and was interested in the ancient world.
Patryk had a diagnosis of schizophrenia and a history of suicide attempts in the community. He was under the care of community mental health services at the time of his arrest.
On 17 April 2023, Patryk was remanded to Wandsworth prison awaiting extradition to Poland. This was his first time in prison in the UK, and he spoke limited English. Despite this, prison and healthcare staff did not use formal interpreting services to communicate with him. Patryk became invisible in prison, demonstrated by the fact that there were no NOMIS case- notes on his record for 227 days and 147 consecutive days.
On 5 January 2024, an officer found Patryk ligatured in his cell. She called for assistance and called a medical emergency ‘code blue’. Staff began CPR until paramedics arrived. Patryk was taken to St George’s Hospital where he died on 19 January. Patryk was found to have self-harm marks on his thighs.
Evidence heard at the inquest was that Patryk developed further symptoms associated with his schizophrenia such as hearing voices but yet no steps were taken to address this or refer Patryk for a psychiatric assessment despite showing clear signs of deterioration.
Now an inquest jury has found that Patryk died having hung himself from a ligature, his intentions in doing so remain unknown. The jury also found that the following are likely to have possibly contributed in more than a minimal way to Patryk’s death:
ENDS
NOTES TO EDITORS
The family is represented by INQUEST Lawyers Group members Sarah Kellas and Aisha Bailey of Birnberg Peirce and Paul Clark of Garden Court Chambers. They are supported by INQUEST Caseworker Jordan Ferdinand-Sargeant.
Other Interested persons represented are HMP Wandsworth, the Ministry of Justice and Oxleas NHS Trust.
Relevant background information
On 9 May 2024, Her Majesty’s Inspectorate of Prisons (HMIP) issued an urgent notification for HMP Wandsworth following an unannounced inspection and concerns including the high rates of self-harm and number of self-inflicted deaths. It also noted that around half of the population were foreign nationals and services had not been designed with this in mind.
In May 2025, HMIP published an Independent Review on Progress on the prison. It found that the rates of violence and self-harm had both reduced.
However, former Wandsworth prisoners and relatives of current prisoners who spoke at the recent open meeting disputed the claims of improvement, saying that conditions inside the jail remain dire.
In 2022, INQUEST published a report on the deaths of racialised people in prison and the role of racism in the preventable and premature deaths of 22 racialised people in prison.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
Make a Donation
Every year, INQUEST supports hundreds of families bereaved by deaths involving the state. We are independent of government and entirely reliant on grants and donations to continue our vital work.
Support us and bereaved families in the fight for truth, justice and accountability by becoming a regular donor today.
Donate now
Related items
We campaign to halt prison expansion and reduce the prison population
Subscribe to our newsletter
To receive the latest news from INQUEST straight into you inbox please subscribe. For examples of what you will receive, see our previous newsletters.