Father of Three Dies in Pentonville Prison Four Days After Remand Despite Suicide Warning
A loving father of three tragically took his own life just four days after being remanded to HMP Pentonville, despite the prison receiving explicit warnings about his high suicide risk. Gareth Chumber-Kelly, aged 33 and from Enfield, was sent to the overcrowded Victorian jail in Islington on July 13, 2023, while on remand. He had been accused of attempting to rob a Post Office on Billet Road in Walthamstow using a BB gun, according to official court documents.
Systemic Failures and Coroner's Concerns
Since Gareth's untimely death, a total of twelve individuals have lost their lives at Pentonville Prison, with at least five of these deaths confirmed as self-inflicted. In a stark prevention of future deaths report directed at the prison, Coroner Jonathan Stevens emphasized grave risks to life stemming from what he described as "slow and inefficient" administrative processes. The report further criticized significant failures in training staff on suicide risk management protocols and a persistent absence of mandatory life support training for personnel.
Gareth arrived at the facility with a documented suicide warning due to his extensive history of self-harm. Alarmingly, the prison administration, the contracted healthcare provider, and the dedicated mental health team all neglected to act upon this critical information. During the jury inquest into his death, it was revealed that essential paperwork from Gareth's initial night in custody was misplaced. Despite exhibiting self-harming behavior while on the detoxification wing, no mental health referral was initiated, directly contravening the prison's internal policies and procedures.
Inadequate Safety Measures and Falsified Records
Following an incident, a safety protocol known as an ACCT was supposedly implemented, placing Gareth under hourly observations. However, the inquest uncovered that key sections of this vital document were missing, no individualized care plan identifying potential triggers was established, and Gareth was left unattended in his cell with access to dangerous items. Scheduled twice-daily welfare conversations were frequently skipped, and those that did occur were described as brief and superficial.
The mandated observations were not consistently carried out, and there was compelling evidence of falsified log entries on July 17, 2023. One prison officer confessed to fabricating an entry for the last time Gareth was seen alive by staff, an act believed to have occurred during the subsequent emergency response efforts.
The Final Hours and Emergency Response Failures
On July 17, a cellmate discovered Gareth in the act of attempting to take his own life and successfully intervened. Tragically, just after 12:30 PM, the same cellmate found Gareth again and immediately pressed the emergency call button. The prison officers who responded were reported to have "froze and panicked," failing to administer crucial CPR until medical assistance arrived, notably without a defibrillator. In a further catastrophic error, prison healthcare staff mistakenly stood down the emergency code blue alert upon arrival after confusing Gareth's cellmate with the actual patient in distress.
Gareth was later pronounced dead at University College Hospital. The coroner's jury identified a "range of failings" by the prison authorities, including the failure to provide necessary life-saving support, inadequate review of medical records, breakdowns in transferring critical care information, the absence of mental health support or proper welfare checks, and insufficient risk assessments regarding his cell environment. The jury partly attributed these systemic failures to critically low staffing levels and a prison lockdown that occurred during the crucial hours leading to his death.
Family's Anguish and Calls for Justice
Saroj Chumber, Gareth's grieving mother, expressed her profound devastation: "My son Gareth came round for dinner on Wednesday, was arrested on Thursday, taken to Pentonville prison on Friday and died on Monday. Gareth was handed a death sentence without even having been found guilty. Me and my daughter Francessca, Gareth’s sister, have been broken by his death and nothing will ever be the same again."
She continued, "Gareth was a very important and vital part of our three-unit family. We are completely broken without him; he was my only son and Francessca's only sibling. His presence, smile and chatter lit up the room and our lives. He was so full of life and always on the go. He can never be replaced. The suffering my son went through in only four days at HMP Pentonville and the way he died is not something I will ever get over. I feel his human rights were breached every step of the way."
"Since Gareth’s death, there have been several more self-inflicted deaths in HMP Pentonville. Every time I hear that someone else has suffered the way Gareth did, it’s a big kick in my face. These deaths must stop. Pentonville prison must be closed down so that no one else has to go through what Gareth and our family went through."
Damning Inspection Reports and Legal Commentary
A scathing inspection report released the previous year detailed "appalling treatment and conditions" at the Category B prison. The report found that 44 percent of inmates felt unsafe, cited a significant ingress of drugs, and reported high levels of violence. Shockingly, fifty percent of prisoners reported experiencing bullying or victimization by staff, some of whom were found sleeping or absent while supposed to be supervising vulnerable individuals.
Kate Litman, a Caseworker at INQUEST, stated: “At the inquest, prison staff tried to paint a picture of Pentonville as a welcoming and supportive place of care and rehabilitation. This is grossly offensive to Gareth's family and insults the public's intelligence. Prison was so unendurable that Gareth took his own life after just four days at Pentonville. Every agency that was supposed to protect Gareth failed to act on a clear warning that he was at risk. The person who did the most to protect Gareth was his cellmate."
Anna Thomson of Bhatt Murphy solicitors added: "Gareth’s death raises serious concerns about the safety of other vulnerable people in HMP Pentonville who, due to the nature of the regime, are completely reliant on the support of prison staff and organisations operating within the prison."
