On 30 January 2026, a jury in Bow Coroner’s Court returned a conclusion following an inquest into the death of Gareth Chumber-Kelly. Gareth, 33, had been identified as being at risk of suicide prior to his arrival at the prison, but the jury found that this risk was not engaged with or addressed by the prison. Numerous failings were identified including: a lack of mental health support; failure to share important information; and insufficient checks for a ligature in Gareth’s cell. The jury also found that low levels of staffing had a cumulative impact. The jury found that Gareth “was not given the necessary support to preserve his life”.
Gareth died on 17 July 2023 after applying a ligature in his cell, only four days after being remanded to HMP Pentonville.
Evidence was heard at the inquest regarding information about Gareth’s risk not being acted upon by the prison and multiple deficiencies in the ACCT process, including missed observations and even falsified entries on the ACCT document.
Following the inquest, on 9 February 2026, HM Assistant Coroner Jonathan Stevens made a Preventing Future Deaths report raising a number of serious concerns including that there had been no suicide and self-harm training for staff at HMP Pentonville since the Covid-19 pandemic, despite the fact that 38% of prisoners arriving at the prison said they felt suicidal and that 7 prisoners had died by ligature suspension since June 2021.
See INQUEST’s press release here.
See Gareth’s mother, Saroj’s, interview on ITV news here.
Read the Prevention of Future Deaths Report here.
The family is represented by Catriona McGregor and Anna Thomson of Bhatt Murphy instructing Shanthi Sivakumaran of Doughty Street Chambers. The family are supported by INQUEST.
For further information please contact Catriona McGregor at Bhatt Murphy on 020 7729 1115 or c.mcgregor@bhattmurphy.co.uk.
