29th October 2015

On Friday 23 October 2015, the jury at the inquest into the death of Carl Foot returned a highly critical narrative conclusion identifying a number of failures by prison staff and senior management which contributed to Carl's death.

33-year-old Carl died on 9 December 2014 in the Royal London Hospital, having been found hanging in his cell in HMP Pentonville on 5 December.  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. He was due to attend court again on 5 December. 

The inquest heard that during Carl’s 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 did not read Carl’s medical records from previous sentences and told the inquest that she was unable to do so because they did not come up on the prison computer system. Carl had scarring on his arm from previous self-harm but this was not seen by the nurse conducting the assessment, nor by the doctor at a medication review the following day.  He received warnings for negative behaviour on 1 and 3 December.   On 4 December Carl told his brother in law, who was also a prisoner in HMP Pentonville at the time, that he hoped to be released from court the following day and intended to spend time with his family.  

Due to an administrative error between the court and the prison, Carl was not called to attend court on 5 December.   He was given a further negative behaviour warning in the morning and in the early afternoon was placed on the basic regime. Carl’s cellmate was moved in the morning of 5 December, and Carl was left alone in the double cell. At some point following the third negative behaviour warning, three officers attended Carl’s cell to remove his television. Carl did not react well. At 1.53pm Carl began to press his cell bell repeatedly, turning it on 8 times in the next 5 minutes.

The inquest heard that an officer went to Carl’s cell and repeatedly cancelled the bell as soon as it had come on, before walking away while the bell was still on. A prisoner in the cell opposite Carl gave evidence to the inquest that Carl told the officer that he was going to kill himself. The officer replied “do it if I care”, before walking away.   Carl’s cell bell was pressed a further 4 times from 2.01pm until Carl pressed his bell for the final time at 2.51pm. No officers gave evidence to having answered any of these 4 calls. The inquest heard that all officers knew that they were expected to respond to cell bells within a maximum of 5 minutes.  Carl’s final cell bell, pressed at 2.51pm, was answered at 3.18pm by an officer from another wing who happened to be walking past. The bell had been unanswered for 27 minutes. 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.

The jury concluded that had Carl been found  found sooner there would have been a greater chance of survival.  They also stated that the staff shortages in the prison were a contributory factor.  Leaving Carl alone in his cell when he was most vulnerable and confiscating his TV and downgrading him to basic regime were also identified as contributory factors. Other failures they identified included:

  • The initial assessment by the nurse and the doctor failed to recognise evidence of self-harm on Carl’s body.
  • Medical records were not discussed or reviewed
  • There was an administrative failure between court and prison regarding Carl’s court appearance.
  • There was an inadequate response to the bells from prison officers. Bells were not answered within the required 5 minutes.
  • There was a failure of senior management to implement an effective control system regarding cell bells.

Deborah Coles, co-director of INQUEST said:

“Carl’s death is another shocking reminder for the prison service that lessons are just not being learnt.  11 years ago Paul Calvert was also found hanging in the same prison whilst officers were playing back gammon rather than answering his cell bell.    These deaths are unacceptable.   Chief Inspectorate of prisons recently found that the  prison was overcrowded, understaffed, and lacked management and leadership. Those comments chime with the jury's conclusions in this case."

For  further information please see:http://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2015/06/Pentonville-web-2015.pdf)

 INQUEST has been working with Carl Foot's  family since February 2015.   The family is represented by INQUEST Lawyers Group members Jo Eggleton from Deighton Pierce Glynn solicitors and barrister Jesse Nicholls of Doughty Street Chambers.