4 November 2022

Before H.M. Deputy Senior Coroner, Philip Barlow
Inner South London Coroner's Court
Concluded 3 November 2022

Yesterday an inquest concluded into the death of Liridon Saliuka, 29, whilst on remand at HMP Belmarsh. The jury found that numerous instances of ill treatment of a discriminatory and dismissive nature, along with an insufficient willingness to address Liridon’s concerns negatively impacted on his mental health and contributed to his death.

Liridon’s is one of 15 deaths of men in HMP Belmarsh since 2015, five of which were reported to be self-inflicted.

Born in Kosovo, Liridon came to the UK with his family aged seven following the outbreak of war. A proud family-man, his sister described him as “thoughtful, funny, loving and caring.”

In January 2018, Liridon was involved in a near fatal car accident which left him in a coma and with life changing injuries. Following his discharge from hospital, he was bed bound for three months and required round the clock care. He suffered from ongoing pain, mobility problems and PTSD following the accident and found it extremely difficult to come to terms with his new condition.

On 17 July 2019, Liridon was remanded to prison custody, awaiting trial. The prosecution case changed two months later to one of joint enterprise., where the prosecution pursues an individual who can be jointly convicted of an offence committed by someone else as if they were the main perpetrator. He always maintained his innocence and was determined to clear his name at trial. After three days at HMP Thameside, he was moved to HMP Belmarsh.

From the moment he arrived, Liridon’s concerns and health needs were largely met with disbelief and dismissal, an experience shared by many racialised people in prison. More than once his disabilities were dismissed because he used the gym. A Senior Officer told the inquest that he’d discounted Liridon’s disabilities because he was “a big character” and “not wasting away”.

On 23 August, Liridon was moved to a disabled access cell where he had access to an orthopaedic mattress and soft chair. These were only available in an adapted cell. He was also assigned a care and support orderly by the local authority to assist with cleaning his cell and other tasks he was unable to carry out due to his disabilities.

Liridon had been expected to be acquitted of his charges at his trial on in January 2020. However, on 13 December 2019 his trial was adjourned until June. This was a source of anxiety and meant he would now have to spend a further six months in prison. This took his imprisonment on remand beyond the legal time limit of six months total.

On 24 December, a Consultant Orthopaedic Surgeon  carrying out a medical report for the defence in Liridon’s upcoming trial, concluded that Liridon’s injuries as a result of the car accident were significant and progressive with lifelong implications in addition to satisfying the criteria under the Equality Act. He also diagnosed Liridon with PTSD.

Shortly before Christmas Liridon was told by prison staff that he had to move out of his disabled access cell to a standard cell for security reasons. On 24 December, at Liridon’s request, the GP recorded that Liridon had a special mattress and chair. Over the following days, Liridon was repeatedly told by prison staff that he had to move. He was asked to move again on 27 December but refused because he knew the GP had authorised his equipment., As a result, he was put on basic regime losing access to privileges such as the gym and put on report for refusing an order. 

Liridon usually called his family at least twice a day but they did not hear from him at all on 27, 28 and 29 December. They raised concerns with the prison but these were not acted upon. Liridon eventually called his family around 5.30pm on 30 December to say that he had been downgraded to basic regime for refusing to move cells and had not left his cell since 26 December. Liridon was upset and emotional on the call. He told his family that he felt he had no option but to agree to the move.

On 30 December a Governor stated that Liridon’s move be put on hold until his needs were confirmed.  Despite this, a hearing took place that morning in Liridon’s absence, even though he wanted to attend, where further punishments were imposed. Liridon was moved the following morning,

On 2 January, Liridon complained to a health care assistant about being without his mattress. He said he had been sleeping on the floor. Later that morning Liridon and the prisoner assigned to help him argued so Liridon wasn’t unlocked to collect his lunch. When officers took it to him Liridon refused to go back into his cell and was restrained. After the restraint he remained locked in his cell. An officer responded to his cell bell at 12.23pm but staff did not check on him again until 5.25pm. He was found unresponsive and could not be resuscitated.   

The jury found that Liridon’s death was suicide following significant and multiple failings. There were repeated failings to consistently recognise the fact and extent of Liridon’s disability resulting in further failure to implement reasonable adjustments, specifically relating to the provisions of an adequate mattress and to conduct an adequate medical assessment, prior to completing the move from the medical cell. These were significant failures in the co-ordination of Liridon’s care, with inadequate record keeping. There were numerous instances of ill treatment of a discriminatory and dismissive nature, along with an insufficient willingness to address Liridon’s concerns.

The jury considered the above to have negatively impacted on Liridon’s mental health and thus constitute contributing factors to Liridon's suicide.

Dita Saliuka, sister of Liridon Saliuka said: “My brother, Liridon, passed away at the hands of the state. From the jury’s conclusions it is painfully obvious, the very people that were meant to be protecting his life, contributed to his death. There is no greater injustice than losing an innocent loved one under the roof of a prison, where no matter how many questions are answered, they provide little comfort or closure. Too many people lose their lives in our prisons, and year after year, lessons aren’t learnt, or recommendations followed. Despite the inquest concluding that significant and multiple failings and numerous instances of ill treatment of a discriminatory nature led my brother to take his own life it provides me with little hope that anything will change. There wasn’t even anyone from the prison in court to hear the damning conclusion from the jury. I can only hope that change will come. 

Each time a preventable and unnecessary death occurs at the hands of the state, the system becomes less trustworthy for those who live in it, and for their loved ones. Even though this chapter is now closing, the heartache lives on in me and my family and the question remains, but why? He was a loved son, brother, uncle and friend who will be greatly missed and while he was ‘just’ a prison number to the state, he was a human being to his family and friends. There needs to be more accountability on those whose actions lead to prisoner’s deaths, and I will continue to fight for justice for Liridon and the families in our position, as well as families who unfortunately will tragically find themselves in this position one day.”

Selen Cavcav, Senior Caseworker at INQUEST, said: This damning indictment confirms yet again that our prisons are unsafe and unable to provide basic levels of care.  Liridon was a young man in despair both in relation to his physical disabilities and his mental state and entirely relied on prison and healthcare staff to provide him with basic duty of care. What he was met with instead was punishment and total dismissal of his needs.”

Jo Eggleton of Deighton Pierce Glynn solicitors, who represent the family, said: “Liridon was extremely close to his family. Family was everything to him. Dita campaigned tirelessly to clear his name and was clearly a huge support to him in prison. Since his entirely preventable death she has fought for truth, accountability and change for her brother and others who die in prison custody. This burden shouldn’t fall on bereaved families.”



For further information, please contact Leila Hagmann on [email protected].

The family is represented by INQUEST Lawyers Group members Jo Eggleton and Nkiru Okafor of Deighton Pierce Glynn Solicitors and Jamie Burton (KC) of Doughty Street Chambers.

Other interested persons represented at the inquest are Ministry of Justice and Oxleas Foundation NHS Trust.

Since 2015, 22 racialised people have died in prison. INQUEST’s ground-breaking new report exposes deeply concerning patterns affecting people from racialised groups which contribute to premature and preventable deaths in prison. Key issues uncovered include the neglect of physical and mental health, the failure to respond to warning signs, and the bullying and victimisation of racialised people.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.