26 October  2017 

On Friday 20th October 2017, the jury at the inquest into the death of Jagjeet Samra returned a critical narrative conclusion identifying crucial failures by G4S prison authorities and staff.

36-year-old Jagjeet was found hanging in his cell on 26 May 2016 in HMP Parc – a prison run by G4S.  

Jagjeet was subject to suicide and self-harm management in the prison and was required to be observed every half an hour. This was conducted by a live CCTV camera which was displayed in the SCU office.  On the night of 25th May 2016, Jagjeet was able to take his own life by using a ligature point in a blind spot within his cell which was not visible on the CCTV camera.

The officer on duty that night had recorded in the observation record that Jagjeet was completing a jigsaw puzzle at the three observations from 10.30pm onwards.  In fact, the CCTV subsequently showed that Jagjeet was not visible at all on the camera at any of these checks.  He was not visible on the CCTV camera for a period of over two hours, without any check of his cell being conducted. 

When the officer finally did decide to conduct a check, which was prompted by hearing a bang, it took approximately thirty minutes for another officer to join him in order for them to enter the cell.  On entry, Jagjeet was found hanging.  

The jury found that his observations were ‘inadequate’ and ‘conducted contrary to policy’ and that it was inappropriate that assistance was not requested sooner.   Since Jagjeet’s death the Prison Officer who was responsible for the observations has been dismissed. 

Strikingly, the jury also identified systemic failures in the overseeing of the suicide and self-harm management system by the G4S prison allowed for the individual failure to make adequate observations of Jagjeet. A senior member of management from the G4S prison accepted that there was no system of “spot checking” officers observations to monitor that individuals were conducting their observations correctly. 

Following representations made by the family, the Coroner agreed to write to the Ministry of Justice and G4S to raise concerns regarding staffing levels and cell design.   

Mandeep Samra, the brother of Jagjeet, said:

“On behalf of the Samra family I would like to start of by saying Jagjeet was a loving and generous young man and had the potential to be someone. Unfortunately he got caught in the wrong crowd which led him into prison. However, he did not deserve to be treated the way he was at HMP Parc.

The two week inquest highlighted many systematic failures on behalf of HMP Parc. Some including failure to carry out observations and monitor CCTV Cameras within the Safer Custody Unit to ensure my brother could be seen. He was a vulnerable individual at risk of self-harm and required twice hourly observations but it was evident this task was not carried out for over two hours. 

Only one member of staff is on duty during the night within the Safer Custody Unit. This led to delays in opening the door to my brothers cell when the guard realised he was not in sight of the camera. The time waiting for assistance could be the difference between life and death.

Management at HMP Parc had no process in checking the reliability of the observations carried out by staff. For example spot checks are not carried out to check the written observations against CCTV recordings. This would have left the night officer to not undertake his hourly checks correctly and log in false timings and information.

If these points had been undertaken back in May 2016 it could have possibly prevented Jagjeets death”.

Selen Cavcav, senior caseworker from INQUEST said:

“The jury’s conclusion in Jagjeet’s inquest, once again brings scrutiny to private companies who continue to fail to provide basic care for prisoners who are in crisis.  We hope that the systemic failures which have been identified by the jury do not gather dust and that proper action is taken on the ground to prevent future deaths”

INQUEST has been working with Jagjeet’s family since July 2016. The family is represented by Catherine Oborne of Garden Court Chambers and Matt Foot of Birnberg Peirce & Partners.



INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.