Gareth Chumber-Kelly · Prevention of Future Deaths report

On 26th July 2023, I commenced an investigation into the death of Gareth Chumber-Kelly (aged 33). The investigation concluded at the end of a 10-day inquest before a jury on 30th January 2026.

The conclusion of the inquest was:

The deceased took his own life and the risk of his doing so was not recognised, nor were appropriate steps taken to try to prevent him from doing so.

The jury found that:

‘Gareth came to his death via suspension ████████ in HMP Pentonville. Gareth was pronounced dead at University College Hospital on 17th July 2023.

The jury finds that Gareth’s medical history and immediate circumstances posed a clear risk to his life. This risk was clearly identified outside the prison, but due to a range of failings was not engaged with or addressed by the prison. As such, Gareth was not given the necessary support to preserve his life. Specifically, the failures included inadequate review of medical records, the failure to ensure the continuity of important information in the transfer of care, a failure to provide Gareth with any of the mental health support available or timely provision of a welfare call. Insufficient checks were given to the risk of ligature in Gareth’s cell.

The jury also finds that the low levels of staffing and subsequent lockdown during crucial hours of Gareth’s time in prison had a cumulative impact. Other contributing factors included the lack of staff training and inadequate cover during break hours.’

Medical cause of death was found to be:

1 (a) Suspension

Gareth Chumber-Kelly was taken into custody at HMP Pentonville on Thursday 13th July 2023. Prior to his arrival he had spoken to a Forensic Mental Health Practitioner at the Court Liaison and Diversion Service and told her he would take his own life if he was remanded in prison. The Forensic Mental Health Practitioner was concerned about the risks of self-harm and she sent a hard copy of her Liaison and Diversion Report, together with a Suicide and Self Harm (“SASH”) warning form to the HMP Prison Pentonville via Serco, together with copies by e-mail to the mental health services team operating within the prison.

For reasons that were not established, there was no evidence that the hard copy of the Liaison and Diversion Report was with the documentation that was received by the prison staff on Mr Chumber-Kelly’s arrival at Pentonville, although the SASH form was received. The court heard, however, evidence that it was quite common for forms that were supposed to accompany prisoners to go missing.

Mr Chumber-Kelly had a known history of self-harm when he had previously been in prison, and had previously attempted suicide on two occasions whilst in the community. He had a history of opioid dependence and was suffering from withdrawal symptoms from drugs.

On Friday 14th July 2023 Mr Chumber-Kelly self-harmed (on two occasions) and he was put on an ACCT (Assessment, Care & Custody Teamwork) and put on hourly observations, although the evidence was that not all observations were carried out despite having been recorded as done.

In the morning of Monday 17th July 2023 Mr Chumber-Kelly’s cell-mate woke to found him standing with a noose around his neck but was able to ‘talk him down’.

Later that same morning Mr Chumber-Kelly’s cellmate awoke again and found Mr Chumber-Kelly hanging ████████. He pressed the cell alarm (at 12.35).

A prison officer, who had worked at the prison for 24 years, arrived at the cell, called a ‘Code Blue’ emergency and cut Mr Chumber-Kelly down, but did not attempt any CPR. A second officer arrived shortly afterwards and also failed to tender any CPR.

Prison healthcare staff then arrived and commenced CPR, pending the arrival of the emergency services. Mr Chumber-Kelly was taken by ambulance to University College Hospital in London where despite further administration of life support measures, he was pronounced dead.

(1) The court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would be sometimes be lost. This creates a risk to the safety and well-being of prisoners as the documentation accompanying the prisoner as they are conveyed to prison may contain (as was the case with Mr Chumber-Kelly) very important information about the prisoners which is relevant to ensuring all appropriate steps and measures are put in place to protect them. The Governor at HMP Pentonville told the court that no steps have been taken to address this recurrent problem, and the risk of important documentation being lost, and there has been no dialogue with Serco to address this issue.

(2) The court heard evidence that 2 prisoners had died by ligature suspension (on 17.6.2021 and 1.3.22) prior to Mr Chumber-Kelly’s death, and that since then a further 5 prisoners have died by ligature suspension (one of which was Mr Chumber-Kelly). The Governor of HMP Pentonville told the court that Suicide and Self harm training for prison staff had been suspended during Covid and had never been re-started notwithstanding that 38% of prisoners arriving at HMP Pentonville said they felt suicidal and notwithstanding that 7 prisoners have died by ligature suspension since June 2021. The failure to train prison officers in the risks and management of suicide and self-harm creates a risk of future deaths.

(3) The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so. Both officers described how they panicked and did not know what to do. The court heard evidence from a consultant paramedic from the London Ambulance service with extensive experience in resuscitation who explained that for every minute without CPR there is a 10-22% drop in survival rates. It is critically important that the first person on the scene in such emergency situations (who will almost always be the prison officers) are properly and regularly trained in basic life support so that they are able to render such aid immediately on arrival. The Governor of the prison told the court that no refresher CPR training had been provided to prison staff since 2023 notwithstanding the 5 deaths of prisoners by ligature suspension that have occurred since. This is deeply concerning given that this very same issue was raised in a Prevention of Future Deaths Report by Mary Hassell, HM Senior Coroner of Inner North London on 18th September 2023 relating to the death of Amarjit Singh and yet in the 2 years since that PFD was issued there is still no mandatory basic life support training for prison officers.

The failure of the prison to provide regular, mandatory basic life support to all prison officer creates a risk of future deaths.