Note slipped under door of man's prison cell - 45 minutes later he was dead

A prisoner was found dead less than an hour after he received a disciplinary notice under the door .

Lewis Petryszyn, 25, was serving a sentence of three years and 10 months at for trafficking Class A drugs and intentionally wounding a man outside Swansea's Fiction nightclub. An inquest at Pontypridd Coroners' Court heard how in April 2022 staff at the prison found a ‘debt list’ in Mr Petryszyn’s cell and he was moved to another unit due to "concerns about his behaviour”. On April 14 he tested positive for a psychoactive substance and the next day a prison officer went to his cell to give him paperwork for a disciplinary hearing.

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reported how less than an hour later the alarm was raised when Mr Petryszyn was found slumped on the floor.

Staff found he was unresponsive and died when resuscitation attempts failed. The coroner concluded he died from the inhalation of drugs.

Now the ombudsman has highlighted a string of errors at the jail where Petryszyn had been imprisoned in 2021.

Ombudsman Kimberley Bingham wrote: "[The officer] told us he looked through the cell door observation panel, thought that Mr Petryszyn and his cellmate were asleep, and slid the paperwork under the door.

"She found Mr Petryszyn slumped on the floor and his cellmate sitting on his bed, staring into space.

The post-mortem found two types of illicit psychoactive substance in his system as well as an antipsychotic, olanzapine – which he had not been prescribed – and one of his prescribed antidepressants, mirtazapine.

The ombudsman found local policy was breached by the officer who put the paperwork under the door rather than handing it to the inmate in person. The report added: “This meant staff missed a possible opportunity to provide emergency medical care to Mr Petryszyn sooner.”

The ombudsman wrote she was concerned by the availability of psychoactive drugs at the jail as well as the problem of prescribed medication being sold on. The report also criticised the prison pharmacist for prescribing Mr Petryszyn two antidepressants, mirtazapine and fluoxetine, at the same time.

According to guidelines only a doctor with specialist experience should prescribe two antidepressants of this class together.

Last month a damning report into Parc found a failure to tackle an "alarming" flow of drugs led to "a spate of tragic deaths". The inspection concluded standards had "declined significantly" from 2022 because of private security giant G4S winning a 10-year contract to run the jail.