Prevention of Future Deaths reports · 2026
Regulation 28 report to prevent future deaths, reference 2026-0125, written 3 Mar 2026. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Mar 2026 |
|---|---|
| Reference | 2026-0125 |
| Deceased | Mujahid Adam |
| Coroner | Edwin Buckett |
| Coroner area | Inner North London |
| Category | 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.
Regulation 28: Prevention of Future Deaths report
Mujahid Adam (died 21.3.2025)
THIS REPORT IS BEING SENT TO:
(1)
, The Governor, HMP Pentonville,
Caledonian Road, London N7
(2) The Secretary of State for Justice, Ministry of Justice, 102
Petty France, Westminster, London SW1H 9AJ
(3) The Minister of State for Prisons, Parole and Probation, 102
Petty France, Westminster, London SW1H 9AJ
1
CORONER
I am: Edwin Buckett
Assistant Coroner
Inner North London
Poplar Coroner’s Court
127 Poplar High Street
London E14 0AE
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On the 27th March 2025 Assistant Coroner Saba Naqshbandi KC began
an investigation into the death of Mujahid Adam who died aged 20, on
the 21st March 2025 at University College Hospital, Euston Road, London
NW1 following his transfer there from HMP Pentonville.
The investigation concluded at the end of a 7-day inquest, on 24th
February, 2026 conducted by myself, Assistant Coroner Edwin Buckett
sitting with a Jury at Bow Coroner’s Court.
The jury made a determination at inquest that the deceased died as a
result of suicide with a number of possible contributory causes to his
death.
1
4
CIRCUMSTANCES OF THE DEATH
The Jury findings as to the circumstances of death were recorded in the
Record of Inquest at Paragraph 3 as follows:
“Mr Adam had a history of low mood and mental health issues.
He was facing a serious criminal charge and possible deportation.
He was the victim of a violent assault in a previous cell,
and possibly fearful of transfer to another wing.
He made a suicide attempt by ligature on 19.2.2025.
He was placed on constant watch and under the ACCT process and he
was getting regular assessments.
.
On 15.3.2025, no adequate observation was made on his cell between
11.42 and 12.18.
At 12.18, prison staff discovered him hanging in his cell.
The Code Blue signal was delayed, as was cutting him down.
Resuscitation was attempted and he went to University College
Hospital.
He was declared dead on 21.3.2025.”
The conclusion of the Jury as to the death was recorded on the Record
of Inquest at Paragraph 4 as follows:
“Mr Adam’s unstable mental health possibly contributed to his death.
There was a failure to perform observations at an appropriate
frequency, in accordance with the ACCT policy.
There was a delay in calling Code Blue and cutting him down.
These matters possibly contributed to his death.
The cell’s condition possibly provided a greater opportunity to attempt
suicide.”
5
CORONER’S CONCERNS
2
During the course of the inquest, the evidence revealed matters 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 MATTERS OF CONCERN are as follows.
Evidence was given that:
1. If a prisoner was on 15-minute observations, a record of the
observation checks on that prisoner would be made by a prisoner
officer tasked with the responsibility for carrying out those checks.
2. That individual would write down those checks alongside their
name, on a Form which was attached to the AACT Form in the
office on the Wing. It was stated that it was not practicable to note
observation checks as and when they occurred, because the
officer concerned was not allowed to take the ACCT Form on the
wing.
3. Furthermore, on rare occasions a record of such 15-minute
checks might be made ‘in one go’ at the end of a shift. In other
words, this could lead to more than 25 separate entries being
written up in one go (assuming the same officer was expected to
complete checks over 7 hours in a shift).
4. What amounted to a satisfactory observation of a prisoner is not
defined by the prison. Evidence was given by a prisoner officer
that he carried out checks at some distance away from the cell
door. He stated that he did not always walk up to the door and
look in, but relied upon the fact that he could see through the
Perspex Outer cell door as the Inner Metal cell door was fully
open.
5. The cell in which Mr Adam had been placed was in a state of
disrepair. It was possible to access hidden scraps of bedding
material for making a ligature, in a gap in the wall, where the u-
bend of the toilet entered the wall.
6. Although the cell was subject to a daily “accommodation and
fabric check” it was probable that this disrepair, in this location in
this cell was missed by prison staff carrying out AFCs.
I am concerned that:
(a) The recording of observations of 15-minute checks is not
contemporaneous and is prone to inaccuracy. It relies on a prison
officer walking from the cell to the wing office to record
3
observations, every 15 minutes, which may not be realistic if a
prison officer has other duties to perform;
(b) There is no clear definition of what constitutes an “observation”
and how this should be done by staff at the prison when someone
is on 15-minute observations;
(c) The cell occupied by Mr Adam is one of a handful of special cells
in the prison which are used for vulnerable prisoners on constant
watch or on 15-minute observation. It was in a state of disrepair
and gave access to the hidden material from which a ligature
could be made. Despite daily AFCs, that disrepair was not noted
although this was a special cell.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that 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 1st May 2026. I, 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 following.
• HHJ Alexia Durran KC, the Chief Coroner of England & Wales
• The Family of Mujahid Adam
• The Prisons & Probation Ombudsman (PPO).
I am 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
4
representations to me, the coroner, at the time of your response, about
the release or the publication of your response by the Chief Coroner.
9
DATE 3.3.2026
SIGNED BY ASSISTANT CORONER
Edwin Buckett
5
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.
Edwin Buckett Assistant Coroner for Inner North London Poplar Coroner’s Court 127 Poplar High Street London E14 0AE Email: Director General of Operations HM Prison and Probation Service 8th Floor Ministry of Justice 102 Petty France London SW1H 9AJ 28 April 2026 Dear Mr Buckett, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR MUJAHID ADAM Thank you for your Regulation 28 report of 3 March 2026 following the inquest into the death of Mujahid Adam at HMP Pentonville on 21 March 2025. 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 Adam’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 delivery of observations as part of the Assessment, Care in Custody, Teamwork (ACCT) document, the definition of an observation and the condition of constant supervision cells at HMP Pentonville. All newly recruited prison officers receive a full day of training on suicide and self-harm prevention as part of their initial prison officer training, which includes modules on the ACCT process. During this training, staff are taught that observations are checks to ensure the welfare of the individual and that they must satisfy themselves that an individual is safe when conducting them. Officers are also advised that they must adhere to the frequency of observations set by the ACCT case review team for prisoners at risk of suicide and self-harm. To ensure staff’s continuous understanding, 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 measures to officers, including what constitutes an observation and how to perform one. Prisoners may require more frequent observations depending on their level of risk, which can be labour intensive for staff. As you have noted, staff do not carry the ACCT document with them when conducting an observation. This is to mitigate the risk of other prisoners becoming privy to sensitive information about the individual being supported. It is also impractical for a member of staff to carry a large document whilst conducting their duties as it would restrict their ability to respond effectively to any emerging incidents. Due to this, the documenting of observations cannot be contemporaneous and must be completed after the event. Staff are required to complete these observations and record them either immediately or as soon as practicable afterwards, alongside their other duties. HMPPS recognises that there may be occasions when this is not feasible; in such circumstances, prisons may make local decisions regarding staffing on the wing to ensure staff feel able to record the required observations. In response to concerns about the condition of constant supervision cells at HMP Pentonville, I can confirm that a bid has been submitted to upgrade these cells to ligature resistant specifications. This work will address any disrepair and reduce opportunities for prisoners to use the fabric of the accommodation to ligature. In addition, staff at HMP Pentonville have been reminded of their responsibility to complete daily accommodation fabric checks. These are physical checks of all prisoner living areas, including cells, to ensure that the area is clean, decent and fit for purpose. They are also valuable opportunities for staff to identify anything that raises suspicion, including items that can be used to ligature. The Duty Governor is required to ensure that the accommodation fabric check book has been signed before staff leave the establishment and to take appropriate action where necessary. 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
See every Prevention of Future Deaths report matching Suicide (from 2015), and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.