A prisoner at HMP Hull who took his own life after admitting murdering his father should have had his mental health reviewed, an independent report has found. Lukasz Lukasik, 36, stabbed his father to death in Selby in December 2020.
Failings in clinical care and the emergency response were identified in a Prisons and Probation Ombudsman report published last week. At an earlier inquest, Mr Lukasik’s death was recorded as “suicide”.
He was remanded into custody at HMP Hull, charged with murder, in January 2021. A nurse who completed Mr Lukasik’s initial health screen noted he was a Polish speaker with good English.
On January 5, a social worker in the Mental Health Liaison and Diversion Services discussed with healthcare staff how Mr Lukasik had presented while in police custody. An assessment under the Mental Health Act 1983 concluded he displayed some evidence of mental illness and drug-induced psychosis, but he was not considered suitable for hospital detention.
Mr Lukasik was described as “calm and polite with no evidence of delusional thinking”. The same day, a nurse completed a secondary health assessment and he claimed he had PTSD caused by a history of physical abuse from his father.
The nurse made a referral to the prison’s mental health service. The next day, a mental health nurse saw Mr Lukasik and they noted that he had “fleeting thoughts of suicide but did not intend to harm himself”.
He said that he felt anxious when he first came to prison and was assessed as having a moderate level of anxiety and depression. But he also said he planned to “get a job and gain IT qualifications”.
In May, Mr Lukasik attended Leeds Crown Court by video link and changed his plea from not guilty to guilty. He was found dead in his cell 13 days later.
The PPO report said prison and healthcare staff were unaware of the change in his circumstances. It said HMP Hull had no standard procedure for assessing whether there had been a change in risk for prisoners after they attended video link court hearings.
There was a 14-minute delay between staff being unable to see Mr Lukasik in his cell and returning to check on him again. An emergency code was not called for a further seven minutes.
Although this did not affect the outcome for Mr Lukasik since he “had been dead for some time”, the ombudsman said it “could make a critical difference in future medical emergencies”. The clinical reviewer found clinical and mental healthcare Mr Lukasik received at Hull was “not equivalent to that which he could have expected to receive in the community”.
HMP Hull accepted all the PPO’s recommendations and took action. The inquest into Mr Lukasik’s death was carried out in December 2023 and the Coroner was satisfied that the recommendations had been actioned appropriately.
A Prison Service spokesperson said: “We have accepted and actioned the Prison and Probation Ombudsman’s recommendations including reminding staff of their role in emergencies and the use of correct emergency codes.”
Healthcare provision in prisons is the responsibility of the NHS or private provider. At the time, this was City Health Care Partnership CIC.
A spokesperson for City Health Care Partnership CIC said: “City Health Care Partnership CIC (CHCP) cannot disclose any details about the care of individual patients as this would be a breach of confidentiality; we no longer provide healthcare services in prisons. We would like to extend our sincere condolences to Mr Lukasik’s family and friends.”
For confidential support, Samaritans can be contacted for free around the clock 365 days a year on 116 123.