Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0106, written 24 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Feb 2025 |
|---|---|
| Reference | 2025-0106 |
| Deceased | Isaiah Olugosi |
| Coroner | Richard Furniss |
| Coroner area | West London |
| Category | State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
West London Coroner Service 25 Bagleys Lane, Fulham, London, SW6 2QA REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Date: 24 February 2025 Case: THIS REPORT IS BEING SENT TO: Scrubs CORONER , Governor of HMP Wormwood I am Richard Furniss, HM Assistant Coroner for West London CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 1 2 http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 1 April 2022 an investigation was commenced into the death of Isaiah Adekunle OLUGOSI. The investigation concluded at the end of the inquest on 21 February 2025. The conclusion of the inquest was Suicide 3 1a Asphyxia 1b Hanging 1c II CIRCUMSTANCES OF THE DEATH The Deceased hanged himself in his prison cell overnight on 27/28 March 2022. The jury found that this was suicide. 4 He had spoken to his wife at about 2100 hours on 27 March 2022. She believed he was suicidal and likely to take his life. She, and Cambridgeshire Police and the Metropolitan Police, were all unable to contact he prison by telephone to warn them. It later transpired that this was because the calls were being diverted to an unmanned or obsolete number. The Deceased's wife drove from Cambridge to the prison, two hours away. She stood outside the main gate for some considerable time, banging on it, calling out and pressing a buzzer which promised to connect her to an intercom through which she could speak to prison staff. The intercom was out of action and had been for several years. In the result, the Deceased's wife and the police could not contact the prison all night During that night, the Deceased took his life. CORONER'S CONCERNS During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. - 5 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. ACTION SHOULD BE TAKEN 6 In my opinion action should be taken to prevent future deaths and I believe you, , Governor of HMP Wormwood Scrubs, have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21 April 2025. I, the coroner, may extend the period. 7 Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Person, (via her solicitors Messrs Hodge, Jones and Allen), who is the Deceased's wife. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 24 February 2025 9 Signature Richard Furniss, HM Assistant Coroner for West London
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Richard Furniss HM Assistant Coroner for West London 25 Bagley's Lane London SW6 2QA Email: Michelle Jarman-Howe Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 2 May 2025 Dear Mr Furniss, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS - ISAIAH OLUGOSI Thank you for your Regulation 28 report of 24 February 2025 following the inquest into the death of Isaiah Adekunle Olugoi at HMP Wormwood Scrubs, which was sent to the Ministry of Justice. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations. I know that you will share a copy of this response with Mr Olugosi’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority. 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. 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. 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. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance regarding the purpose and use of this system. Yours sincerely, Director General of Operations
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