Pentonville Prison Faces Scrutiny After Inmate Suicide Under Constant Watch
A North London prison has been sharply criticized by a coroner following the tragic suicide of a 20-year-old inmate who was supposed to be under constant supervision. Mujahid Adam, a prisoner at HMP Pentonville in Islington, took his own life in March 2025 despite being placed on suicide watch after a previous attempt.
Systemic Failures and Delayed Response
The inquest into Mr. Adam's death revealed that prison officers failed to check on him as frequently as required, even though he was in a special cell designated for inmates at high risk of suicide. After his second attempt on March 15, 2025, staff took over 30 minutes to discover him in his cell and further delayed triggering an emergency signal. He was rushed to University College Hospital but died six days later.
Coroner Edwin Buckett warned the Governor of Pentonville that systemic issues at the institution likely contributed to the death. Key problems included inadequate record-keeping, as officers were not allowed to take observation forms onto the wing, leading to welfare reports being written inaccurately at the end of shifts.
Unclear Procedures and Cell Conditions
The inquest found that the prison's definition of a "satisfactory" observation was ambiguous, resulting in some officers conducting checks from a distance, such as behind transparent doors, rather than approaching cells directly. Additionally, the jury noted that the condition of Mr. Adam's cell may have provided greater opportunity for his suicide attempt.
Second Suicide Highlights Ongoing Issues
This coroner's report marks the second issued to HMP Pentonville this year. In January, an investigation into the suicide of inmate Gareth Chumber-Kelly in July 2023 uncovered similar institutional failings, including poor staff training and inadequate responses to suicide warnings.
Mr. Chumber-Kelly, 33, took his own life just four days after being remanded to the prison. Officers on the scene admitted to panicking and not knowing what to do, and the prison, healthcare provider, and mental health team all failed to act on his history of self-harm. The jury attributed these failures partly to low staffing levels and a prison lockdown during critical hours.
Broader Concerns at Pentonville
In 2025, a damning report by the Chief Inspector of Prisons revealed that over a third (38%) of prisoners felt suicidal upon arrival at Pentonville. Since July 2022, there have been five self-inflicted deaths at the prison, with three occurring in 2025 alone.
HMP Pentonville is now required to respond to the coroner's reports into the deaths of Gareth Chumber-Kelly and Mujahid Adam by April 7 and May 1, respectively, amid growing calls for reform to address these systemic safety issues.
