PFD report

Isaiah Adekunle OLUGOSI · Prevention of Future Deaths report

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Issued 24 Feb 2025•West 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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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 raised2

  1. Failure to recognise the necessity of a working buzzer/intercom system
  2. Failure to provide a working buzzer/intercom system
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Replacing the intercom is not considered justifiable at present because its limited use and operational impact do not warrant the significant cost.

    Stated by HM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 recognise the necessity of a working buzzer/intercom system

Wider context from the report

“The buzzer/intercom system must have been provided because it was thought important to provide that additional means of communication between the prison and the outside world. In this case, a working system would have enabled the Deceased's wife to warn the prison of his impending suicide. This could happen again in the future if there was another problem with the telephone system during the night state. It is difficult to understand why the buzzer/intercom system has not worked for several years. There was evidence that it is irreparable. But the proposed solution appeared to be either to leave it as it is (still not working) or to remove it altogether. The jury found that the failure to provide a working buzzer/intercom system was a failure. It is a matter of concern that the prison/the Ministry of Justice still considers that it is unnecessary. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 provide a working buzzer/intercom system

Wider context from the report

“The buzzer/intercom system must have been provided because it was thought important to provide that additional means of communication between the prison and the outside world. In this case, a working system would have enabled the Deceased's wife to warn the prison of his impending suicide. This could happen again in the future if there was another problem with the telephone system during the night state. It is difficult to understand why the buzzer/intercom system has not worked for several years. There was evidence that it is irreparable. But the proposed solution appeared to be either to leave it as it is (still not working) or to remove it altogether. The jury found that the failure to provide a working buzzer/intercom system was a failure. It is a matter of concern that the prison/the Ministry of Justice still considers that it is unnecessary. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Replacing the intercom is not considered justifiable at present because its limited use and operational impact do not warrant the significant cost.

Verbatim wording from the response

“The intercom system itself was identified in October 2024 as requiring complete replacement at significant cost. Again, as described at the inquest given its limited use and impact on routine operations this cost is not considered justifiable at present. In order to prevent confusion, the Governor has ordered the external system units be removed.”

Source location

Response from HMPPS
Page 1 · response
Published 26 February 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The intercom was not designed or intended for members of the public to contact the prison and is not a standard Prison Service requirement.

Verbatim wording from the response

“Following evidence heard during the inquest you have queried the purpose and function of the intercom system at the prison. In responding to your specific query, I can confirm that systems of this type are not a standard requirement across the Prison Service and it is not the case that the intercom system was designed or intended to be used for people trying to contact the prison. Given the nature of prison security and in particular night staffing it would not be expected that people would try and contact the prison by attending in person.”

Source location

Response from HMPPS
Page 1 · response
Published 26 February 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Resolve prison phone-line issues, ensure public access at all times, and regularly test the line.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.
  2. 2

    Order removal of the external intercom system units to prevent confusion about contacting the prison.

    Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 February 2025.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Resolve prison phone-line issues, ensure public access at all times, and regularly test the line.

Verbatim wording from the response

“I was extremely sorry to hear that Mr Olugosi’s wife was unable to contact the prison by the phone number available to her and recognise the distress this undoubtedly will have caused. As you heard in evidence, the prison has addressed the phone line issues and thereby ensured that anyone can call the prison at any time, and that this is regularly tested.”

Source location

Response from HMPPS
Page 1 · response
Published 26 February 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Order removal of the external intercom system units to prevent confusion about contacting the prison.

Verbatim wording from the response

“The intercom system itself was identified in October 2024 as requiring complete replacement at significant cost. Again, as described at the inquest given its limited use and impact on routine operations this cost is not considered justifiable at present. In order to prevent confusion, the Governor has ordered the external system units be removed.”

Source location

Response from HMPPS
Page 1 · response
Published 26 February 2025

Open published response
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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