Carl Robert FOOT · Prevention of Future Deaths report

On 11 December 2014, I commenced an investigation into the death of Carl Robert Foot, aged 33 years. The investigation concluded at the end of the inquest on 23 October 2015.

The jury made a narrative determination, which I attach.

Mr Foot was found hanging in his cell at HMP Pentonville.

• That morning, he had been told that he would be moving cells to a different wing. This was simply to accommodate his methadone prescription, but he did not want the move and was angry as a consequence.

• He then racially abused a prison officer and was put on a basic regime. His television was taken away.

• He later realised that he had not been taken to court that day as he should have been.

The jury concluded that Mr Foot did not actually intend to take his life.

Between 1.53pm and 2.51pm on the afternoon of his death, Mr Foot rang his cell bell 13 times.

On occasion, including the last occasion, it was left up to 27 minutes before being answered by a prison officer, rather than within the expected five minutes. Mr Foot was found at 3.18pm by a passing prison officer. He was resuscitated, but died four days later in hospital. If he had been found earlier, he would have had a better chance of survival.

1. The jury found that there was an inadequate response by prison officers to the cell bells, and that this was a contributory factor in Carl Foot’s death.

2. Once a cell bell has been pressed, unless they remember hearing it and the time of hearing it, officers on the landing have no way of knowing when the bell was pressed, in other words, how long the prisoner has been waiting. That makes it more difficult to prioritise appropriately.

3. In terms of learning lessons for the future, which may include learning by individual officers as well as on a systemic basis, there was no exploration immediately after Carl Foot’s death of the cell bell log and all those who heard/answered his bell that afternoon. By the time of inquest, memories had faded.