PFD report

David Andrew Llewellyn O’GARRO · Prevention of Future Deaths report

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Issued 16 Jun 2014•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
4

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised4

  1. Failure to accurately record cell occupancy suitability
    Part of recurring concern: Unreliable recording of prisoner risk assessments and decisions
  2. Failure to ensure reliable communication of healthcare cell-sharing instructions to prison officers
    Part of recurring concern: Unsafe cell-sharing decisions for prisonersPart of recurring concern: Unsafe interoperability between prison custody and healthcare procedures
  3. Lack of staff knowledge and shared understanding of cell sharing risk assessment requirements
    Part of recurring concern: Unsafe cell-sharing decisions for prisoners
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to accurately record cell occupancy suitability

Wider context from the report

“The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy. No HMP Pentonville CSRA was ever found for Mr O’Garro. During the inquest: - one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate; - a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works; - one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book. Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville. ”

Is this part of a recurring concern?

Yes — Unreliable recording of prisoner risk assessments and decisions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to ensure reliable communication of healthcare cell-sharing instructions to prison officers

Wider context from the report

“The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy. No HMP Pentonville CSRA was ever found for Mr O’Garro. During the inquest: - one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate; - a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works; - one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book. Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville. ”

Is this part of a recurring concern?

Yes — Unsafe cell-sharing decisions for prisoners; Unsafe interoperability between prison custody and healthcare procedures.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of staff knowledge and shared understanding of cell sharing risk assessment requirements

Wider context from the report

“The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy. No HMP Pentonville CSRA was ever found for Mr O’Garro. During the inquest: - one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate; - a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works; - one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book. Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville. ”

Is this part of a recurring concern?

Yes — Unsafe cell-sharing decisions for prisoners.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to complete and retain cell sharing risk assessments

Wider context from the report

“The nurse who carried out the first reception screen of Mr O’Garro did not complete a cell sharing risk assessment (CSRA) indicating that he should share a cell, though she told me she knew that a person with epilepsy should not occupy a cell alone. She completed the computer record indicating that he was fit for any cell occupancy. No HMP Pentonville CSRA was ever found for Mr O’Garro. During the inquest: - one prison nurse appeared at times completely unfamiliar with the CSRA, and wholly unclear as to how to ensure (in 2012 or now) that prisoners with epilepsy would have a cellmate; - a prison doctor said that a locum doctor working at the prison might not even complete a CSRA because s/he would not know how the prison works; - one of the prison officers was unsure how a message from healthcare regarding cell sharing would reach any particular officer if s/he was away on the day it was entered into the observation book. Whilst I appreciate that you are making significant changes to the reception process for new prisoners, there appeared at inquest to be a lack of clarity and shared understanding among those working at HMP Pentonville. ”

Is this part of a recurring concern?

Yes — Unsafe cell-sharing decisions for prisoners.

Open source report
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026