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He was sent to the overcrowded jail after he was accused of attempting to rob a Post Office
A loving dad-of-three took his own life just four days after he was remanded to HMP Pentonville, despite the prison being warned of his suicide risk. Gareth Chumber-Kelly, 33, from Enfield, was sent to the overcrowded Victorian jail in Islington while on remand on July 13, 2023, after he was accused of attempting to rob a Post Office on Billet Road, Walthamstow, with a BB gun, according to court documents.
Since Gareth’s death, 12 people have died at Pentonville Prison. At least five of these deaths were self-inflicted. In a prevention of future deaths report to the prison, Coroner Jonathan Stevens highlighted risk to life resulting from the “slow and inefficient” paperwork, failures to train staff on suicide risk management, and a continued lack of mandatory life support training.
Gareth arrived at the prison with a suicide warning, due to his long history of self-harm. But the prison, the healthcare provider, and the mental health team, all failed to act on this information, and important paperwork from Gareth’s first night was lost, a jury inquest into his death heard. Despite self-harming while on the detox wing, no mental health referral was made, contrary to internal policy.
After the incident, a safety plan known as an ACCT was put in place, with Gareth under hourly observations, however the inquest heard key sections of the document were missing, no care plan was put in place identifying triggers, and Gareth was left in his cell with dangerous items. Twice-daily conversations were skipped, and the ones that were completed were brief, the court heard.
The observations were not always carried out, and there was evidence of falsified entries on July 17 2023. One prison officer even admitted faking an entry the last time Gareth was seen alive by staff, which is understood to have happened during the emergency response.
On July 17, a cellmate found Gareth attempting to take his life but persuaded him not to. Just after 12:30pm, the same cell mate found Gareth again and pressed the emergency button.
The prison officers who did attend ‘froze and panicked’, failing to deliver CPR until medical help arrived without a defibrillator. Prison healthcare staff also stood down the code blue on attending the call after confusing Gareth’s cellmate with the patient.
Gareth was later pronounced dead at University College Hospital. The jury found a “range of failings” by the prison, including: not giving necessary support to save his life; inadequate reviewing of medical records; failing to ensure continuity of important information in the transfer of care; failing to provide Gareth with mental health support or a welfare call; and insufficient checks on the risk in his cell. The jury partly attributed these failings to low staffing levels and a prison lockdown during the crucial hours.
Saroj Chumber, Gareth’s mother, said: “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.
“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.”
A damning inspection report, released last year, found “appalling treatment and conditions” at the Category B prison, with 44 per cent of inmates feeling unsafe, an ingress of drugs, and high levels of violence. Fifty per cent of prisoners reported that they had been bullied or victimised by staff, some of whom were found sleeping or absent when they were meant to be supervising vulnerable men.
Kate Litman, Caseworker at INQUEST, said: “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, said: “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.”
Got a story? Please email callum.cuddeford@reachplc.com
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