Inquest jury finds failure of HMP Pentonville to act over previous deaths contributed to self-inflicted death of 28-year-old

9th December 2016

Before Coroner Mary Hassell at St Pancras Coroners Court

A jury at the inquest into the death of Tedros Kahssay this week concluded that the failure by HMP Pentonville to act over previous deaths contributed to the circumstances surrounding the 28-year-old taking his own life.


The jury also found serious errors by police, prison and Care UK healthcare staff, including the failure of police and prison officers to record or share essential information relevant to his level of risk.


Tedros, 28, was found hanging in his cell on 19 January 2016. The coroner described scenes of “chaos” as staff employed by Care UK – the private company providing healthcare at the prison – attempted to revive him. Two days earlier, Tedros had told staff he did not feel safe on the wing and banged on his cell door with a chair, saying he needed to get out.


The jury concluded that:


  • Tedros’ person escort record (PER) – a document designed to ensure that all staff have information about a prisoner’s risks or vulnerabilities – did not flag the appropriate suicide risk;


  • The record was not passed to healthcare staff by prison staff, contrary to the requirements of the system that was in place at the time, which meant that staff were unaware of his history of depression;


  • No holistic overview was taken of Tedros’ risk factors and the risk assessment process was compromised;


  • HMP Pentonville did not comply with recommendations made by the Prisons and Probation Ombudsman following a previous death at the prison - that of Carl Foot in December 2014. This failure impacted on the adequacy of the mental health assessment.


Tedros was an Eritrean national who had been granted asylum after fleeing his home country. The inquest heard that he had been a victim of torture.


He was the fifth man since April 2013 to take his own life at HMP Pentonville. Like the others, he died within the first month of his incarceration. The Prison and Probation Ombudsman (PPO) have made an almost identical recommendation in each of the five cases concerning the assessment of the risk of suicide and self-harm in the early days of custody.


The inquest heard that both the prison and the head of healthcare had accepted a PPO recommendation requiring the sharing of information with healthcare. This recommendation followed the death of Satheeskumar Mahathevan in January 2014 and was repeated after the death of Carl Foot in December 2014. Neither the prison governor nor the deputy head of healthcare were able to explain why this had not been implemented. A further two self-inflicted deaths have occurred at the prison since January.


The family’s solicitor Jo Eggleton said: “This is yet another example of previous recommendations for improvement not being taken seriously and acted upon. It’s incomprehensible that something as fundamental as the PER is not seen by healthcare staff on reception. The governor and Care UK need to act immediately to ensure that it is always seen by reception healthcare staff.”


Deborah Coles, director of INQUEST, said: “Care UK is the biggest private provider of healthcare to the UK’s prison service.  They have been seriously criticised in several recent prison deaths.  It is truly disturbing to hear of their chaotic response in this case and their apparent inability to even perform effective CPR.   We need to know how these failures being reflected in the granting of such significant public contracts and how is it that Pentonville were able to ignore the implementation of significant recommended changes following previous deaths at the prison.”


INQUEST has been working with Tedros’s family since immediately after his death in January. Tedros’s family are represented by Inquest Lawyers’ Group members Jo Eggleton, of Deighton Pierce Glynn, and Jesse Nicholls, of Doughty Street Chambers.






For more information, please contact Jo Eggleton at Deighton Pierce Glynn at [email protected] or 020 7378 4739 or Laura Smith at INQUEST on [email protected] or 020 7263 1111.




  1. Care UK was granted the healthcare contract for HMP Pentonville in 2014. It was previously provided by Whittington NHS Trust.
  2. On 20 December 2015, Tedros was arrested on suspicion of murdering his pregnant partner. The police completed his PER form but failed to record the nature of the allegation against him – despite mandatory guidance, which states that an allegation of violence against a partner is a particular risk factor for self-harm and suicide and must be recorded in the PER. A number of witnesses told the inquest that knowledge of the allegation would have informed their risk assessments and could or would have made them act differently.
  3. On arrival at HMP Pentonville on 21 December, Tedros was assessed by a number of prison officers but none passed the PER to healthcare staff. All healthcare witnesses told the inquest that both at the time of Tedros’s death and still today, healthcare staff are not provided with the PER. The deputy head of healthcare at the prison admitted that he did not know the PER document should go to healthcare staff.
  4. At the health screenings on his arrival, Tedros reported suffering from depression. Despite his background and the nature of the allegation against him, no psychiatric referral was made. One of the nurses who assessed Tedros accepted that had he been provided with the relevant information, he would have referred him to a psychiatrist.


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.