Gareth Chumber-Kelly

Dear Mr Stevens,

Thank you for your Prevention of Future Death Report (‘PFDR’) dated 9 February 2026 following the conclusion of the Inquest into the death of Gareth Chumber-Kelly who sadly died in July 2023 at HMP Pentonville.

As the Managing Director of Serco’s Justice and Immigration business, I am responding on behalf of Serco and Antony Kirby, Serco’s Group Chief Executive Officer to matters of concern that you have raised in the PFDR, in so far as they relate to Serco under the Prisoner Escort and Custody Services (PECS) contract. I am aware that you will share a copy of this response with Mr Chumber-Kelly’s family and I would like to express my sincere condolences for their loss. Every death in custody is a tragedy, and the safety of those detained and transported by Serco is our absolute priority.

I am grateful to you for bringing the matters of concern to Serco’s attention. However, before addressing those concerns, I feel obliged to express my surprise that a PFDR was issued against Serco in this case. As you will be aware Serco were not identified as an interested person in the Inquest, and were not given an opportunity to provide any evidence in relation to Mr Chumber-Kelly’s time in Serco’s custody to demonstrate that we not only complied with our obligations and followed the appropriate processes to keep Mr Chumber-Kelly safe, but also passed on all risk information to the receiving prison. You may not be aware that there are commercial and reputational implications for Serco if a PFDR is issued against us, and it seems particularly unfair for us to be subject to such implications without the opportunity to address the court’s concerns in advance of a PFDR being issued against us. However, I understand that the concerns only came to light at the very end of the Inquest, during PFD evidence from the Governor of HMP Pentonville and therefore anticipate that you may not have had the opportunity to raise them with Serco whilst the case was being prepared for Inquest, or during the Inquest itself.

It is noted that the jury’s narrative conclusion into Mr Chumber-Kelly’s death confirmed that his medical history and immediate circumstances posed a clear risk to his life and that this risk was clearly identified outside the prison. However, due to several failings on the part of the prison, which were listed by the jury, the risk was not addressed. It is further noted that a Suicide and Self-Harm warning form (SASH) was completed by a mental health practitioner whilst Mr Chumber-Kelly was in Serco’s custody and that this very important document was handed over by Serco staff to prison reception staff, therefore fulfilling Serco’s duty of care obligations to Mr Chumber-Kelly at that point. I understand that the prison staff accepted during evidence that this document had been received, reviewed and that the document confirmed that Mr Chumber-Kelly had stated that he would kill himself if he was remanded to prison. The known risks were therefore communicated to the prison, to allow them to take action to keep Mr Chumber- Kelly safe.

However, I note that your PFDR states that for reasons that were not established, there was no evidence that a hard copy of a Liaison and Diversion report completed by the mental health practitioner was with the documentation that was received by prison staff on Mr Chumber-Kelly’s arrival at Pentonville. If Serco had been granted IP status it is of course possible that evidence could have been provided in relation to the missing document. However, it is also noted that the court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would sometimes be lost. Having not had the opportunity to provide representation, or even be present at the Inquest, it is not

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clear whether their evidence was that the documentation could sometimes be lost as a result of the stated inefficiencies, or alternatively as a result of any failings on the part of Serco PECS staff. However, it is noted that there is no mention of the prison’s reception staff being critical of Serco in your PFDR, and that the jury made no findings of any failings on Serco’s part. It appears from the PFDR that the first mention of any issue involving Serco was when the Governor at the prison was giving PFD evidence. It is understood that he also confirmed that there had been no dialogue with Serco in relation to the ‘missing documentation’.

The court may not be aware that Serco PECS conduct monthly stakeholder meetings with HMP Pentonville, where performance updates, emerging issues, complaints, and other relevant matters are discussed and follow-up actions are agreed. Clearly these meetings would have been the correct forum for such suggested concerns about missing documentation to be raised. To our knowledge, there are no confirmed instances of missing paperwork being escalated to Serco staff by the Prison’s management team in these forums, either before or after Mr Chumber-Kelly’s death. I will however ensure that the Serco representative who regularly attends the stakeholder meetings at HMP Pentonville raises this issue at the next meeting, so that a full and constructive discussion can take place, and any remedial concerns, if there are any, can be resolved.

Thank you again for bringing your concerns to my attention. I can assure you that Serco is fully committed to keeping the often-vulnerable individuals in our care safe and well, and I hope you are reassured by the response to the issue raised.

If I can be of any further assistance, please do not hesitate to contact me.