Jury finds that litany of gross failures amounting to neglect contributed to vulnerable inmate's 'fire trap' death

The Jury, who heard during the course of the inquest that Robert suffered with mental health problems and learning difficulties, concluded that he had died as a result of unintended consequences of his deliberate act contributed to by neglect by the prison. No less than seven ‘gross failures’ were identified.

In the weeks leading up to his death both staff and inmates located on C wing noted that Robert’s mental health appeared to have significantly deteriorated and he was increasingly paranoid. The Jury also heard evidence that a prison ‘listener’ had been called to give support to Robert on 30 July 2013 and that following this appointment the listener had made Robert’s suicidal ideation known to a prison officer. However, no suicide or self harm protective measures were put in place. The officer in question admitted that she should have begun this process to try and help safeguard Robert from harm. This omission was accepted by the Prison Service as a gross failure that contributed to Robert’s death.

It was noted by a prison officer on 4 August 2013, just two days before the fatal fire, that Robert was ‘increasingly paranoid and erratic.’ The following day, on 5 August, Robert was sent back from the prison workshop to his cell early due to his distress. The Jury concluded that either on Robert’s discussion with workshop staff or upon his return to the wing suicide/self harm protective measures should have been put in place and an ACCT document opened. The Jury found that this too was a gross failure that contributed to Robert’s death.

The Jury heard that on the night of 5 August and the early hours of 6 August inmates on C wing smelt a strange, burning smell. This smell was also noted by the two Prison Officers on night duty. Sean Horstead, counsel for the family, established that neither officer had been patrolling the wing correctly and that they had therefore not walked on the second floor landing where Robert’s cell was located during their hourly checks, even as part of their cursory search for the source of the burning smell. One of the Prison Officers on duty on the night of Robert’s death admitted in his evidence that he had continued his practice not to patrol each landing on night duty up to a month before the inquest.

Robert was not found until the day staff came on shift the following morning but by that stage he was past medical help and was pronounced dead by paramedics who were called to attend the scene.

Despite the significant amounts of smoke produced by the fire in Robert’s cell, no fire alarm sounded on the night of his death. The Jury heard evidence that one smoke detector was shared between six cells on three levels and that the detector was located in the roof level ductwork. The air from the cells passed through to that space through a vent in each cell. The Jury heard that the ventilation grille in Robert’s cell was obstructed due to being painted over but that even if it had not been, the system would still not have provided sufficient early warning in order to save Robert’s life.

The fire safety advisor to the governor at HMP Wealstun at the time of Robert’s death stated in his evidence that he had not been aware of the problems with the in-cell fire detection on C wing (and in other parts of the prison) until July 2012. He admitted he had not been aware of information updates circulated nearly a decade before, as early as 2003, by the National Offender Management Service (NOMS) advising of the inadequacies of these systems. NOMS and the Ministry of Justice (MOJ) had directed prisons not to rely solely on these systems for the purposes of protection of life effectively confirming that they were not fit for purpose. Plans were made by HMP Wealstun to upgrade the fire detection systems but in spite of the known risks, absolutely no interim measures were put in place to protect the lives of the inmates before these works began. Just four days before Robert’s death the Crown Premises Fire Inspection Group wrote to the Governor following an inspection confirming that the prison still lacked effective interim measures to mitigate the absence of an in cell fire detection system. This last notice too was effectively ignored.

Part way through the inquest those representing the Prison Service made admissions that the cell occupied by Robert at the time of his death did not have effective protective measures to protect life in the event of a fire. No interim measures were put in place in the period leading up to Robert’s death and in particular there was no adequate system of maintenance of the grilles in the cells. Prison officers were not adequately patrolling the wings at night and there had been no training to make explicit the need to walk down each landing on the wings as part of all patrols.

At the conclusion of the inquest, having heard representations from the family’s barrister Sean Horstead, Assistant Coroner John Hobson indicated that in addition to considering making a range of recommendations under his Regulation 28 Prevention of Future Death powers, he would be writing to West Yorkshire Constabulary to urge a full review of the evidence heard at the inquest in relation to potential breaches of the Regulatory Reform (Fire Safety) Order 2005.

Zbigniew Majchrzak BEM, Robert’s uncle, speaking for the family said:

“It has been a challenging three years since Robert’s death to obtain disclosure of the facts surrounding fire & safety issues from the Prison Service. We feel that if we had not asked the questions and pushed for answers about the circumstances surrounding Robert’s death that the significant failures highlighted during the inquest would never have been made public.

Some key documents relating to fire safety within the prison were disclosed just before the inquest began, others were introduced during the inquest. This evidence had a significant bearing on the outcome of the inquest and in our view, we, as a family should have been made aware of these failings much earlier.

Now that these gross failures have been highlighted the family can now hopefully find some closure.”

Rebecca Treece, solicitor representing Robert’s family said:

"The Jury at this inquest found that a catalogue of gross failures by the Prison Service contributed to Robert Majchrzak’s death. The inquest highlighted the fact that, at the time of Robert’s death, inmates at HMP Wealstun were being locked in cells at night that were referred to by the Coroner at the conclusion of the inquest as ‘fire traps.'

Robert was a vulnerable young man who fell victim to inadequate systems and slack practices within the prison. His family are keen to see evidence of improvements that have been made in relation to each of the failures identified by the Jury during the course of this inquest.”

Deborah Coles, Director of INQUEST said:

"This inquest has demonstrated an alarming disregard for prisoner safety from HMP Wealstun. For a prison to be aware that their fire alarm system was ineffective for almost a decade and yet do nothing to repair it is shocking. Equally worrying is that prison officers failed to undertake required night patrols of all landings even though a burning smell was detected, risking the health and safety of prisoners.

In addition, Robert was a vulnerable prisoner whose mental health needs were not appropriately provided for. This is the case for a large proportion of the prison population. The government must act to divert more people with mental health problems from custody and for those who need to be imprisoned ensure that the necessary support and safe systems are in place.”

INQUEST has been working with the family of Robert Majchrzak since 2015. The family is represented by Sean Horstead of Garden Court Chambers instructed by Rebecca Treece from Lester Morrill Solicitors.

Ends

Sean Horstead is a member of the Garden Court Chambers Civil Liberties and Human Rights Team.

This press release was produced by INQUEST and first appeared on the INQUEST website.

The inquest findings received national press coverage, including in The Guardian.