Prisoner Found Dead After Officer Unaware of Welfare Check Duty at HMP Gartree
A convicted murderer serving a life sentence was discovered dead in his cell by a fellow inmate after a prison officer unlocked his door without performing a mandatory welfare check, a new report has revealed. The officer later told investigators he was unaware such checks were required, believing his sole responsibility was to unlock cell doors.
Details of the Incident
Patryk Skupinski, 38, was found lying face down in a pool of vomit by another prisoner on 29 January 2025 at HMP Gartree in Leicestershire. He had been serving a life sentence with a minimum term of 21 years for the murder of his partner, 32-year-old Marlene Doyle, in Coventry in January 2022.
According to the independent report by the Prisons and Probation Ombudsman, the sequence of events began with a routine roll check at 5.07am, where an officer peered through the observation panel and noted nothing amiss. A further check at 7.13am failed to obtain a response from Skupinski, but the officer did not open the cell door as per prison policy.
At approximately 7.58am, a separate officer unlocked Skupinski's cell door for morning activities without checking on him. Roughly 20 minutes later, a fellow prisoner visited to see if Skupinski was ready for the workshop and found him unresponsive on his bed.
Response and Findings
Prison staff rushed to the scene, placed Skupinski in the recovery position, and began CPR after establishing he was not breathing. Paramedics arrived at around 8.45am and observed rigor mortis, indicating he had likely died two to six hours earlier. He was pronounced dead at 8.58am.
A post-mortem examination determined that Skupinski died from ischaemic heart disease combined with synthetic cannabinoid use. A tampered vape, commonly used to inhale illicit substances, was recovered from his cell. An inquest in March 2026 concluded he died by misadventure alongside an underlying heart condition.
The officer who unlocked the cell stated he was unaware a welfare check was required, with fellow officers also claiming no knowledge of such a policy. The deputy governor said managers would reissue the unlock policy to all staff, requiring signatures to confirm understanding.
Broader Context and Recommendations
The prison has since updated its Local Security Strategy to mandate that staff open cell doors when unable to see the prisoner inside. The report also scrutinised healthcare staff's response, noting that naloxone, used for opioid overdoses, was not administered until ten minutes after their arrival, though this made no difference as Skupinski was already dead.
Throughout his imprisonment, Skupinski had shown no signs of drug use, with positive entries in his record for good behaviour. He worked as a cleaner and later as a mentor in the prison workshop. However, HMP Gartree faces ongoing drug issues, with drones identified as a major method for smuggling contraband.
The Independent Monitoring Board expressed concerns about drug infiltration linked to debt, violence, and bullying. The prison is installing protective cages on windows to combat drone deliveries. Skupinski is the eleventh prisoner to die at Gartree since January 2022.
Family and Aftermath
Skupinski's mother, Hanna Skupinski, had been imprisoned for assisting an offender after her son's crime and was deported to Poland after her release. The prison worked with the Polish Consulate to locate his brother and inform him of the death. Polish authorities arranged for Skupinski's remains to be returned to Poland.
A Prison Service spokesperson said: "HMP Gartree has reviewed its morning check process and is ensuring all staff are aware of its welfare check policy. We have invested over £40 million in new prison security nationally, including £10 million on anti-drone measures, to clamp down on contraband."
