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recurance

Liridon Saliuka

8 Nov 2022 · Coroner Philip Barlow · Inner South London

The coroner's concerns

  1. 1. lack of clear documentation of required disability adjustments

    “no clear documentation (accessible by prison staff, healthcare and social services) of the adjustments that were required for the prisoner's disability”
  2. 2. lack of disability awareness among prison staff

    “lack of disability awareness amongst prison staff of all levels”

Responses

2022-0355-Response-from-HM-Prison-and-Probation-Services.pdf ↗· HMP Belmarsh

Stated action

“Prison Service Instruction (PSI) 32/2011 is the national policy for ensuring equality and it mandates that Governors must ensure that efforts are made to identify whether a prisoner has a mental or physical impairment of any form and that procedures are in place to record this information, while maintaining confidentiality.”

Stated action · 2023

“throughout 2023 HMP Belmarsh will be holding monthly training sessions alongside Oxleas NHS Trust and RGB for all operational staff. These sessions will focus on encouraging staff to think differently about disability, including those that may not be visible, and to take action to improve how they engage with disabled prisoners to ensure their needs are met, and the necessary support is offered.”

2022-0355-Response-from-Oxleas-NHS-Foundation-Trust.pdf ↗· Oxleas NHS Foundation Trust

Stated action · February 2023

“following this inquest the following improvements have now been made. When a patient is identified as requiring adjustments to their disability that these will now be documented on the Prison Nomis (P-Nomis) system. Agreement was reached following senior management review by HMP Belmarsh, Royal Borough of Greenwich Social Care and Oxleas NHS Foundation Trust. All these providers have access to p-nomis. All prison staff have been notified of this development and healthcare administrative staff”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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