24 January 2019

Before Senior Coroner Mary Hassell
St Pancras Coroners Court, Camley St, Kings Cross, London N1C 4PP
Hearing 14 - 22 January 2019

Tyrone Givans was 32 years old when he died from self-inflicted injuries in his cell at HMP Pentonville on 26 February 2018. He was profoundly deaf and had been at the prison for less than three weeks, for the most part without any access to hearing aids. The inquest has concluded finding numerous system and individual failures contributed to his death. 

On 6 February 2018, Tyrone was remanded into police custody. He did not have his hearing aids with him. He also had a history of alcohol misuse, depression and anxiety. A court custody officer completed a suicide and self-harm warning form, detailing Tyrone’s history of self-harm and current low mood. The Person Escort Record (PER) which accompanied Tyrone from court to prison noted that he had said he would self-harm if taken to prison. The PER did not record that Tyrone had also expressed suicidal ideation.

On 7 February 2018, Tyrone was transferred to HMP Pentonville. At the inquest hearing a number of prison staff accepted they should have opened suicide and self-harm monitoring procedures, known as ACCT, had they known of Tyrone's history of suicidal ideation. 

During his time at HMP Pentonville, Tyrone was not referred to the prison Equality Officer and staff failed to put in place reasonable adjustments to accommodate Tyrone's disability.

On 21 February 2018, Tyrone's mother visited him and provided one of his hearing aids, after he had spent over two weeks unable to hear. Tyrone reported that he wanted to move cells and wings as he did not feel safe and his mattress had been slashed when he was out of his cell. He also said that he could not sleep as he would be unable to hear if someone was approaching him. Tyrone raised his concerns with a prison officer on the same day; however, no steps were taken to move Tyrone from the wing or from his cell.

Various healthcare staff at the prison failed to review Tyrone's previous medical records, because two SystemOne records (the medical records used in and available across prison establishments) were created in error. As such, from 8 February 2018, medical staff were not aware of Tyrone’s previous records, resulting in a lack of continuity of care. That day, due to his low mood Tyrone was prescribed antidepressants by prison healthcare staff employed by Care UK. However, this was not reviewed in line with NICE Guidelines.

The inquest jury concluded that collectively the following factors “resulted in Tyrone Givans’ needs not being met and contributed to his death”:

  • Tyrone's alcoholism, substance abuse and profound deafness were insufficiently processed and addressed by the prison and healthcare services;
  • Communication between members of staff was inconsistent and unsatisfactory;
  • The IT systems used for storing prisoners' records were unfit for purpose and there was insufficient integration between different systems;
  • The recording of prison patient records was inadequate, and best practice and established procedures were not followed.

The Senior Coroner, Mary Hassell indicated that she would be making a Prevention of Future Deaths Report. Tyrone’s death was one of ten self-inflicted deaths in Pentonville in the past five years (2014-18). The most recent inspection of HMP Pentonville found, “frailties in the care for those at risk of suicide or self-harm were evident” and the prison was not safe enough. 

Angela Augustin, Tyrone's mother said:
“We are pleased that the jury have rightly acknowledged the failures of the prison and Care UK which contributed to Tyrone’s death. Tyrone was profoundly deaf and very vulnerable. He was scared without his hearing aids and I believe suffered without support at HMP Pentonville. We hope to now move on and grieve the sad and avoidable loss of Tyrone.”

Chanel Dolcy of Bhatt Murphy solicitors who represented the family said:
"This is a tragic case of a wholly preventable death where a series of omissions and missed opportunities left a very vulnerable man who was profoundly deaf with inadequate care and support. We hope that the appropriate agencies ensure that the failings which contributed to Tyrone's death are rectified and not allowed to occur again."

Deborah Coles, Director of INQUEST said:
“The trauma Tyrone must have experienced, newly arrived at prison, experiencing mental ill health, and unable to hear for weeks, is unimaginable. The prison and Care UK failed to provide astoundingly basic levels of care. The failings exposed by this inquest must be acted upon at a national level.”


For more information contact Lucy McKay on [email protected] or 020 7263 1111

The family is represented by INQUEST Lawyers Group members Chanel Dolcy of Bhatt Murphy Solicitors and Adam Wagner of Doughty Street Chambers.

In June 2017 a critical inspection of HMP Pentonville was published by HM Inspector of Prisons.

Between January 2014 to December 2018 there were ten self-inflicted deaths at HMP Pentonville. The most recent death followed Tyrone’s and took place on 29 November 2018.

Previous inquests:

  • On 9th December 2016, the jury at the inquest into the death of Tedros Kahssay 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.

  • On 29th October 2015, the jury at the inquest into the death of Carl Foot returned a critical narrative conclusion identifying a number of failures by prison staff and senior management which contributed to Carl's death.

INQUEST have been calling for a national oversight mechanism on state related deaths for over ten years. The Joint Committee on Human Rights backed this recommendation in their 2017 report on mental health and deaths in prison, where you can find more information.