Inmate was 'isolated and depressed' before death

The inquest heard Rolandas Karbauskas had not had any phone calls or visitors for a "considerable amount of time"

An inmate who was found dead in his cell was "isolated" and had a history of depression and suicide, an inquest has heard.

Rolandas Karbauskas, 49, had arrived at HMP Lowdham Grange on 20 March 2023 from HMP Lincoln and was discovered dead by a fellow prisoner five days later.

He was the third of three inmates to have been found dead at the Category B site within a month, with Anthony Binfield and David Richards having died in the weeks prior.

At an inquest at Nottingham Coroner's Court on Thursday, a jury heard how no formal action was taken to address Karbauskas's mental health issues.

HMP Lowdham transferred from private providers Serco to Sodexo in February 2023

Karbauskas, a Lithuanian national, was first remanded into custody at HMP Lincoln on 19 March 2022, at which point he had a suicide and self-harm warning on his records.

It came to light six months later that a mental health referral that was made for him at the time was never actioned.

The jury inquest heard the inmate "spoke very little English" and required an interpreter for appointments and assessments.

Throughout his time in custody since March 2019, a process used in prison to help those at risk of self-harm or suicide called an ACCT - which stands for assessment, care in custody and teamwork - was never implemented.

When he arrived at HMP Lowdham Grange on 20 March 2023, assistant practitioner Angela Bevis carried out his reception healthcare screening instead of a nurse, "due to staffing levels".

She told the jury she had no formal or specific training on how to conduct such a screening.

'Something wasn't right'

The prison had transferred from private providers Serco to Sodexo in February 2023, and the jury had heard throughout the inquest how it had been understaffed at time of the inmates' deaths.

Ms Bevis said she was not aware of Karbauskas's history of mental health issues because she had not looked beyond the previous six months of his records from HMP Lincoln.

However, the practitioner said she made an "urgent referral" to a mental health team because the inmate "stated he had always suffered with mental health" - through the help of another Lithuanian inmate who translated the conversation.

Ms Bevis added she "didn't want him to feel more isolated than he probably already felt".

That referral - which the court heard should have been actioned within 48 hours -did not happen because an interpreter had not been arranged, despite specific notes on the system in which the referral was logged.

'Depression and anxiety'

Concerns about Karbauskas were also raised by the prisoner who discovered him dead.

Anthony Davies, who had been on the same wing - E wing - held the role of "wing buddy" at the time, which involved offering emotional support to other inmates.

Karbauskas was last seen alive at 16:50 on 24 March before Mr Davies discovered him the following morning at 10:30, the court heard.

He said he heard Karbauskas was Lithuanian shortly after his arrival and wanted to help him, having "picked up" a few words or phrases in Lithuanian.

Mr Davies said it looked as though the inmate "hadn't been looked after" and noticed he was not eating the day before his death.

"There was something definitely not right with that chap, he needed help," Mr Davies said.

The jury was shown footage of Karbauskas giving away food items from his cell in the 24 hours before his death, which Mr Davies said was considered a "red flag" in training he had previously undertaken for the wing buddy role.

Mr Davies told a prison officer about his concern for the new inmate, the jury was told, and efforts were made to bring him food and communicate with him.

A Quaker chaplain at the prison also tried to help the inmate, and noted in a statement read to the jury that Karbauskas "spoke no English at all".

Despite efforts to find an interpreter, the chaplain said nobody who spoke Lithuanian could be found, when she saw him.

She said: "He was a very thin man and I was concerned about him."

A Sodexo prison officer who was seconded to HMP Lowdham from Peterborough at the time was likely the only person who had a full conversation with Karbauskas in his five days at the prison, the jury heard.

The officer said she was asked to translate for Karbauskas during a prison induction in which she recalled him saying he suffered from "depression and anxiety".

During that conversation, the officer said the inmate was told a referral would be made to address these issues.

A lack of access to prison records - an issue she said officers had raised with Sodexo - meant she was not aware of any other referrals made.

"I'm possibly the only person that had had a full conversation with him [at the prison]," she said.

The jury also heard he had not had any phone calls or visitors for a "considerable amount of time".

The inquest continues.

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