Mujahid Adam · Prevention of Future Deaths report

On the 27ᵗʰ March 2025 Assistant Coroner Saba Naqshbandi KC began an investigation into the death of Mujahid Adam who died aged 20, on the 21ˢᵗ March 2025 at University College Hospital, Euston Road, London NW1 following his transfer there from HMP Pentonville.

The investigation concluded at the end of a 7-day inquest, on 24ᵗʰ February, 2026 conducted by myself, Assistant Coroner Edwin Buckett sitting with a Jury at Bow Coroner’s Court.

The jury made a determination at inquest that the deceased died as a result of suicide with a number of possible contributory causes to his death.

The Jury findings as to the circumstances of death were recorded in the Record of Inquest at Paragraph 3 as follows:

“Mr Adam had a history of low mood and mental health issues.

He was facing a serious criminal charge and possible deportation.

He was the victim of a violent assault in a previous cell,
and possibly fearful of transfer to another wing.

He made a suicide attempt by ligature on 19.2.2025.

He was placed on constant watch and under the ACCT process and he was getting regular assessments.

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On 15.3.2025, no adequate observation was made on his cell between 11.42 and 12.18.

At 12.18, prison staff discovered him hanging in his cell.

The Code Blue signal was delayed, as was cutting him down.

Resuscitation was attempted and he went to University College Hospital.

He was declared dead on 21.3.2025.”

The conclusion of the Jury as to the death was recorded on the Record of Inquest at Paragraph 4 as follows:

“Mr Adam’s unstable mental health possibly contributed to his death.

There was a failure to perform observations at an appropriate frequency, in accordance with the ACCT policy.

There was a delay in calling Code Blue and cutting him down.

These matters possibly contributed to his death.

The cell’s condition possibly provided a greater opportunity to attempt suicide.”

Evidence was given that:

1. If a prisoner was on 15-minute observations, a record of the observation checks on that prisoner would be made by a prisoner officer tasked with the responsibility for carrying out those checks.

2. That individual would write down those checks alongside their name, on a Form which was attached to the AACT Form in the office on the Wing. It was stated that it was not practicable to note observation checks as and when they occurred, because the officer concerned was not allowed to take the ACCT Form on the wing.

3. Furthermore, on rare occasions, a record of such 15-minute checks might be made ‘in one go’ at the end of a shift. In other words, this could lead to more than 25 separate entries being written up in one go (assuming the same officer was expected to complete checks over 7 hours in a shift).

4. What amounted to a satisfactory observation of a prisoner is not defined by the prison. Evidence was given by a prisoner officer that he carried out checks at some distance away from the cell door. He stated that he did not always walk up to the door and look in, but relied upon the fact that he could see through the Perspex Outer cell door as the Inner Metal cell door was fully open.

5. The cell in which Mr Adam had been placed was in a state of disrepair. It was possible to access hidden scraps of bedding material for making a ligature, in a gap in the wall, where the u-bend of the toilet entered the wall.

6. Although the cell was subject to a daily “accommodation and fabric check” it was probable that this disrepair, in this location in this cell was missed by prison staff carrying out AFCs.

I am concerned that:

(a) The recording of observations of 15-minute checks is not contemporaneous and is prone to inaccuracy. It relies on a prison officer walking from the cell to the wing office to record observations, every 15 minutes, which may not be realistic if a prisoner has other duties to perform;

(b) There is no clear definition of what constitutes an “observation” and how this should be done by staff at the prison when someone is on 15-minute observations;

(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made. Despite daily AFCs, that disrepair was not noted although this was a special cell.