Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0073, written 9 Feb 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 9 Feb 2026 |
|---|---|
| Reference | 2026-0073 |
| Deceased | Gareth Chumber-Kelly |
| Coroner | Jonathan Stevens |
| Coroner area | London (North) |
| Category | State Custody related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28: REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. The Governor, HMP Pentonville, Caledonian Road, London, N7 8TT 2. , Group Chief Executive, Serco, Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY 3. Secretary of State for Justice, Ministry of Justice, 102 Petty France, Westminster, London, SW1H 9AJ 4. The Minister of State for Prisons, Parole and Probation, 102 Petty France, Westminster, London, SW1H 9AJ 1 CORONER I am Jonathan Stevens, Assistant Coroner, for the Inner North London coroner area. 2 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 Coroner’s (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 26th July 2023, 1 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 4 CIRCUMSTANCES OF THE DEATH 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 1401July 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 bell (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 render 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. 5 CORONER’S CONCERNS HM Chief Inspector of Prisons produced a report in August 2025 following an unannounced inspection of the prison carried out from 30th June - 10th July 2025. The report noted that since the last inspection (in July 2022) there had been 5 self- inflicted deaths (one of which was Mr Chumber-Kelly) and that 3 of those deaths had occurred in 2025. The report noted that deficiencies repeatedly identified in the ACCT process were not given sufficient attention and staff had very limited knowledge of prisoners in their care or the reasons why they were on an ACCT. The report noted that the survey that they had conducted revealed that 38% of prisoners felt suicidal on their arrival at the prison. It was clear from the evidence that many prisoners have complex mental health issues and that the incidence of mental health issues in HMP Pentonville is much higher than generally in the community. The Chief Inspector of Prisons in his letter to the Lord Chancellor and Secretary of State of 16th July 2025, whereby he invoked the Urgent Notification Process because of the poor performance at HMP Pentonville, advised that HM Inspectorate of Prison had inspected HMP Pentonville on 5 occasions since 2015 (2015, 2017, 2019, 2022 and 2025) and on all but one of those inspections the prison scored T (the lowest possible rating) for safety - the exception being 2022 when the prison scored ‘2’, which is still ‘not sufficiently good’. During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows:- (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 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. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 7th April 2026. 1, the coroner, may extend the period. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (i) (ii) (iii) (iv) (v) (vi) (vii) The Family of Mr Chumber-Kelly Practice Plus Group North London Foundation Trust Phoenix Futures North East London Foundation Trust Together UK The Prison & Probation Ombudsman I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9th February 2uzu \~ ' - - w d
2 responses 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.
Jonathan Stevens Assistant Coroner for Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP Michelle Jarman-Howe Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 23 April 2026 Dear Mr Stevens, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR GARETH CHUMBER- KELLY Thank you for your Regulation 28 report of 9 February 2026 following the inquest into the death of Gareth Chumber-Kelly at HMP Pentonville on 17 July 2023. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS). I know that you will share a copy of this response with Mr Chumber-Kelly’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. You have raised concerns regarding the reception process at HMP Pentonville, the training of staff in relation to self-harm and suicide risk management and mandatory basic life support. HMP Pentonville has introduced a digital induction passport to consolidate key risk information from paper records into a secure electronic format. This enables relevant information to be accurately captured, stored, and shared between departments, reducing the likelihood of omissions or data loss during the induction process. To strengthen oversight of early days in custody, the prison has appointed a Head of Early Days with specific responsibility for the reception function. As part of their remit, they are leading a comprehensive review of reception procedures to identify any aspects, such as documentation handling, that may require improvement and to implement any necessary changes. In addition, the group safety team conducts regular early days exercises, which replicate a prisoner’s arrival and induction experience. These assurance activities are used to test the effectiveness and consistency of the reception process in practice, and to identify areas where further improvements may be required. These combined measures are intended to strengthen risk information management, enhance operational oversight, and support continuous improvement of the safety and experience of those entering HMP Pentonville. The Prisoner Escort and Custody Services (PECS) team within HMPPS recognises the importance of the timely and accurate transfer of risk and safeguarding information and treats this as a matter of serious operational priority. Responsibility for the creation, maintenance and clinical transfer of healthcare and associated risk information rests with qualified medical professionals. In this case, Liaison and Diversion (L&D) services are responsible for ensuring that relevant records are effectively shared with receiving prison healthcare teams. The PECS contracts do not place responsibility on PECS suppliers for the physical transfer of hard-copy medical or risk documentation between courts and prisons. Following the implementation of the Book a Secure Move (BaSM) system, the PECS Contract Management Team has ensured that digital Person Escort Records (DPERs) are available for all prisoners moved by PECS suppliers between courts, prisons and police stations. Recent system enhancements enable authorised professionals, including medical practitioners and L&D services, to update a prisoner’s DPER directly following assessment. These updates are visible to receiving establishments once the prisoner is booked in from court or prison, prior to arrival. This digital capability significantly strengthens the effective, safe and timely transfer of critical risk information across the criminal justice system, reducing reliance on hard-copy documentation and mitigating the risk of information loss. With regards to your training concerns, HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention to officers. Additionally, all band 4 staff at HMP Pentonville have now received the Assessment, Care in Custody and Teamwork (ACCT) case review training, which equips them with the skills to be able to provide prisoners at risk of suicide with holistic and person-centred support in their role as ACCT case coordinators. Nationally, all new prison officers receive mandatory emergency first aid training, including instruction in cardiopulmonary resuscitation, as part of their foundation package. To ensure that there is a sufficient level of provision required for an effective emergency response, every prison is required to conduct a first aid needs assessment in accordance with the first aid at work regulations. Within current HMPPS policy, these assessments are required to account for the needs of prisoners whilst in custody and individuals on probation. More widely, HMPPS develops staff capability through refresher courses and communication packages. Materials, including instructional videos, have been developed and are available to staff through E-learning platforms to update and maintain their first aid knowledge and skills. These provide practical guidance on what to do in several potential scenarios that staff may encounter in the course of their duties. The Pentonville Speed School will support this work by utilising Physical Education Instructors, who are qualified first aid trainers, to deliver basic life-saving skills to staff, including training in CPR. These short, practical sessions will ensure that staff receive essential refresher training and thereby increasing their confidence when responding to medical emergencies. In addition, HMP Pentonville is promoting the first aid at work course and encouraging wider staff participation to ensure that key areas of the establishment maintain sufficient qualified first aiders. Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter. Yours sincerely, Interim Director General of Operations
Mr Jonathan Stevens HM Assistant Coroner for Inner North London St Pancras Coroner’s Court, Camley Street London, N1C 4PP 07th April 2026 Dear Mr Stevens, Thank you for your Prevention of Future Death Report (‘PFDR’) dated 9 February 2026 following the conclusion of the Inquest into the death of Gareth Chumber-Kelly who sadly died in July 2023 at HMP Pentonville. As the Managing Director of Serco’s Justice and Immigration business, I am responding on behalf of Serco and Antony Kirby, Serco’s Group Chief Executive Officer to matters of concern that you have raised in the PFDR, in so far as they relate to Serco under the Prisoner Escort and Custody Services (PECS) contract. I am aware that you will share a copy of this response with Mr Chumber-Kelly’s family and I would like to express my sincere condolences for their loss. Every death in custody is a tragedy, and the safety of those detained and transported by Serco is our absolute priority. I am grateful to you for bringing the matters of concern to Serco’s attention. However, before addressing those concerns, I feel obliged to express my surprise that a PFDR was issued against Serco in this case. As you will be aware Serco were not identified as an interested person in the Inquest, and were not given an opportunity to provide any evidence in relation to Mr Chumber-Kelly’s time in Serco’s custody to demonstrate that we not only complied with our obligations and followed the appropriate processes to keep Mr Chumber-Kelly safe, but also passed on all risk information to the receiving prison. You may not be aware that there are commercial and reputational implications for Serco if a PFDR is issued against us, and it seems particularly unfair for us to be subject to such implications without the opportunity to address the court’s concerns in advance of a PFDR being issued against us. However, I understand that the concerns only came to light at the very end of the Inquest, during PFD evidence from the Governor of HMP Pentonville and therefore anticipate that you may not have had the opportunity to raise them with Serco whilst the case was being prepared for Inquest, or during the Inquest itself. It is noted that the jury’s narrative conclusion into Mr Chumber-Kelly’s death confirmed that his medical history and immediate circumstances posed a clear risk to his life and that this risk was clearly identified outside the prison. However, due to several failings on the part of the prison, which were listed by the jury, the risk was not addressed. It is further noted that a Suicide and Self-Harm warning form (SASH) was completed by a mental health practitioner whilst Mr Chumber-Kelly was in Serco’s custody and that this very important document was handed over by Serco staff to prison reception staff, therefore fulfilling Serco’s duty of care obligations to Mr Chumber-Kelly at that point. I understand that the prison staff accepted during evidence that this document had been received, reviewed and that the document confirmed that Mr Chumber-Kelly had stated that he would kill himself if he was remanded to prison. The known risks were therefore communicated to the prison, to allow them to take action to keep Mr Chumber- Kelly safe. However, I note that your PFDR states that for reasons that were not established, there was no evidence that a hard copy of a Liaison and Diversion report completed by the mental health practitioner was with the documentation that was received by prison staff on Mr Chumber-Kelly’s arrival at Pentonville. If Serco had been granted IP status it is of course possible that evidence could have been provided in relation to the missing document. However, it is also noted that the court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would sometimes be lost. Having not had the opportunity to provide representation, or even be present at the Inquest, it is not Serco Justice & Immigration Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY United Kingdom Serco Group Plc, a company registered in England and Wales No. 2048608 Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom clear whether their evidence was that the documentation could sometimes be lost as a result of the stated inefficiencies, or alternatively as a result of any failings on the part of Serco PECS staff. However, it is noted that there is no mention of the prison’s reception staff being critical of Serco in your PFDR, and that the jury made no findings of any failings on Serco’s part. It appears from the PFDR that the first mention of any issue involving Serco was when the Governor at the prison was giving PFD evidence. It is understood that he also confirmed that there had been no dialogue with Serco in relation to the ‘missing documentation’. The court may not be aware that Serco PECS conduct monthly stakeholder meetings with HMP Pentonville, where performance updates, emerging issues, complaints, and other relevant matters are discussed and follow-up actions are agreed. Clearly these meetings would have been the correct forum for such suggested concerns about missing documentation to be raised. To our knowledge, there are no confirmed instances of missing paperwork being escalated to Serco staff by the Prison’s management team in these forums, either before or after Mr Chumber-Kelly’s death. I will however ensure that the Serco representative who regularly attends the stakeholder meetings at HMP Pentonville raises this issue at the next meeting, so that a full and constructive discussion can take place, and any remedial concerns, if there are any, can be resolved. Thank you again for bringing your concerns to my attention. I can assure you that Serco is fully committed to keeping the often-vulnerable individuals in our care safe and well, and I hope you are reassured by the response to the issue raised. If I can be of any further assistance, please do not hesitate to contact me. Yours sincerely, Managing Director, Justice & Immigration Serco UK & Europe Serco Justice & Immigration Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY United Kingdom T: +44 (0)1256 745 900 | F: +44 (0)1256 744 112 | www.serco.com Serco Group Plc, a company registered in England and Wales No. 2048608 Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom
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