20th October 2015

10am, Tuesday 20 October 2015
St Pancras Coroner's Court, Camley Street, London N1C 4PP
Before Senior Coroner Mary Hassel

33-year-old Carl died on 9th December 2014 in the Royal London Hospital having been found hanging in his cell in HMP Pentonville on 5th of December. The inquest into his death will be heard before a jury at St Pancras Coroner’s court from 20 October. The hearing is due to last four days.

Carl had a long history of alcohol and substance misuse and had served a number of prison sentences for crimes related to his substance misuse problems. He had attempted suicide more than once outside prison and had spent time in a psychiatric hospital.

Carl arrived at HMP Pentonville on 21 November to await sentencing for burglary. He was due to attend court again on 5th December.   

The Inquest will hear that during his initial health assessment he told the nurse that  he had no history of mental health problems and no history of attempted suicide or self-harm. The nurse had not read Carl’s medical records from previous sentences.

Carl was housed in a double cell on A wing, the prison induction unit. The inquest will hear he appeared to settle and was working towards a community sentence with a drug rehabilitation requirement.

He received warnings for negative behaviour on 1 and 3 December. He told his brother in law, who was also a prisoner in HMP Pentonville at the time, on 4th December that he hoped to be released from the court the following day and intended to spend time with his family.

The inquest will hear that Carl was not called to attend Court on 5th December. He was given a further negative behaviour warning and placed on the basic regime. Three officers attended his cell to remove his television as prisoners on the basic regime are not permitted to have a television. Carl did not react well.

The inquest will hear from a prisoner who was in a cell opposite that Carl repeatedly pressed his cell bell. Sometimes the bell was immediately cancelled by an officer, sometimes it was left ringing for longer than the target time of  5 minutes. Carl last rang his bell at 2.54pm. When it was answered 24 minutes later by a passing officer Carl was found hanging from a sheet tied to the window bars. He was taken to the Royal London Hospital where he died 4 days later.

Carl’s family hope that the inquest will be able to address the serious questions and concerns they have about the care and treatment Carl received from officers at HMP Pentonville on 5th December and in particular why his concerns were not dealt with and his cell bell was not answered as it should have been.

The family is represented at the hearing by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn solicitors and barrister Jesse Nicholls of Doughty Street chambers.


There has been a highly critical inspection of HMP Pentonville carried out by the Chief Inspectorate of Prisons which stated that at the time of the inspection last September, Pentoville was seriously overcrowded  with 1,236 inmates in cells designed to hold only 913. Almost half of inmates said they felt unsafe. For further info please see: http://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2015/06/Pentonville-web-2015.pdf