Gareth Chumber-Kelly died by suicide four days after being remanded to HMP Pentonville.  An inquest  has found his death resulted from multiple institutional failures, including failing to refer him for appropriate mental health care.   

Following Gareth’s death, 12 people have since died at HMP Pentonville, five of which were self-inflicted deaths.  

On 13 July 2023, Gareth was remanded to HMP Pentonville with a suicide and harm warning, stating he would take his own life if he was sent to prison. This information was not acted on by the prison, healthcare provider or the mental health team. Evidence heard at the inquest found that important paperwork from Gareth’s first night was lost by the prison. After moving to another wing, Gareth engaged in self-harm and, despite internal policies, healthcare staff failed to refer him to the mental health wing.  

Following this, a prison officer created a safety plan called an ACCT, which is used for prisoners who are at risk of suicide or self-harm, and Gareth was placed under hourly observations with two daily meaningful conversations with officers. The inquest found that key sections of the ACCT were inadequately completed, no care plan was put in place to identify risks and triggers, and Gareth was left in his cell with potentially harmful items.  

The inquest found that ACCT conversations were skipped or brief and lacked interaction. It was also found that entries made on 17 July 2023 were falsified, with one prison officer admitting to falsifying the final entry the last time Gareth was seen alive. 

On 17 July, Gareth’s cellmate found him attempting to ligature and persuaded him to stop. The ligature was reportedly left in place. At 12:35pm, Gareth was found ligatured again and the emergency bell was pressed. The two officers who arrived ‘froze’ and ‘panicked,’ making no attempt to resuscitate him. Once healthcare staff arrived, resuscitation was attempted but they admittedly forgot a defibrillator, and further errors delayed an ambulance. The jury concluded that Gareth died by ligature.   

Saroj Chumber, Gareth’s mother said, ‘Gareth was handed a death sentence without even having been found guilty.’ She added that ‘his human rights were breached every step of the way’ and called for an end to ‘these deaths’ in custody. 

Kate Litman, caseworker at INQUEST said, the prison was ‘so unendurable that Gareth took his own life after just four days.’ She added that to ‘safeguard lives, we must dismantle prisons like Pentonville and invest in community alternatives’ to imprisonment. 

Anna Thomson of Bhatt Murphy solicitors, representing the family, said: ‘staff failed to identify his risk or take necessary action to support him.’ Adding that his ‘death raises serious concerns about the safety of other vulnerable’ prisoners who ‘are completely reliant on the support’ of the institution. 

INQUEST has previously stated that self-harm in prisons has reached ‘a new peak since records began in 2004,’ with Director Deborah Coles describing these figures as ‘yet another devastating indictment of the appalling state of the prison system.’