Source · Prevention of Future Deaths

Isaiah Olugosi

Ref: 2025-0106 Date: 24 Feb 2025 Coroner: Richard Furniss Area: West London Responses identified: 1 / 1 View PDF

A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.

Date 24 Feb 2025

56-day deadline 21 Apr 2025

Responses identified 1 of 1

State Custody related deaths Suicide (from 2015)

Coroner's concerns

AI summary

A critical buzzer/intercom system in the prison has been inoperable for years, preventing emergency warnings, and authorities are unwilling to repair or replace it.

View full coroner's concerns

The MATTER OF CONCERN is as follows. -

The buzzer/intercom system must have been provided because it was thought important to provide that additional means of communication between the prison and the outside world. In this case, a working system would have enabled the Deceased's wife to warn the prison of his impending suicide. This could happen again in the future if there was another problem with the telephone system during the night state. It is difficult to understand why the buzzer/intercom system has not worked for several years. There was evidence that it is irreparable. But the proposed solution appeared to be either to leave it as it is (still not working) or to remove it altogether. The jury found that the failure to provide a working buzzer/intercom system was a failure. It is a matter of concern that the prison/the Ministry of Justice still considers that it is unnecessary.

Responses

1 respondent

HM Prison and Probation Service Central Government

2 May 2025 PDF

Action Taken

HMPPS expresses condolences and notes the concerns raised. The prison has addressed phone line issues ensuring the prison can be called at any time and that this is regularly tested. The Governor has ordered the external intercom system units to be removed. (AI summary)

View full response

Dear Mr Furniss,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS - ISAIAH OLUGOSI

Thank you for your Regulation 28 report of 24 February 2025 following the inquest into the death of Isaiah Adekunle Olugoi at HMP Wormwood Scrubs, which was sent to the Ministry of Justice. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

I know that you will share a copy of this response with Mr Olugosi’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

I was extremely sorry to hear that Mr Olugosi’s wife was unable to contact the prison by the phone number available to her and recognise the distress this undoubtedly will have caused. As you heard in evidence, the prison has addressed the phone line issues and thereby ensured that anyone can call the prison at any time, and that this is regularly tested.

Following evidence heard during the inquest you have queried the purpose and function of the intercom system at the prison. In responding to your specific query, I can confirm that systems of this type are not a standard requirement across the Prison Service and it is not the case that the intercom system was designed or intended to be used for people trying to contact the prison. Given the nature of prison security and in particular night staffing it would not be expected that people would try and contact the prison by attending in person.

The intercom system itself was identified in October 2024 as requiring complete replacement at significant cost. Again, as described at the inquest given its limited use and impact on routine operations this cost is not considered justifiable at present. In order to prevent confusion, the Governor has ordered the external system units be removed.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance regarding the purpose and use of this system.

Report sections

Investigation and inquest

On 1 April 2022 an investigation was commenced into the death of Isaiah Adekunle OLUGOSI. The investigation concluded at the end of the inquest on 21 February 2025. The conclusion of the inquest was Suicide 1a Asphyxia 1b Hanging 1c II

Circumstances of the death

The Deceased hanged himself in his prison cell overnight on 27/28 March 2022. The jury found that this was suicide. He had spoken to his wife at about 2100 hours on 27 March 2022. She believed he was suicidal and likely to take his life. She, and Cambridgeshire Police and the Metropolitan Police, were all unable to contact he prison by telephone to warn them. It later transpired that this was because the calls were being diverted to an unmanned or obsolete number.

The Deceased's wife drove from Cambridge to the prison, two hours away. She stood outside the main gate for some considerable time, banging on it, calling out and pressing a buzzer which promised to connect her to an intercom through which she could speak to prison staff. The intercom was out of action and had been for several years. In the result, the Deceased's wife and the police could not contact the prison all night During that night, the Deceased took his life.

Similar PFD reports

Shared signals

Report details

Reference: 2025-0106
Date of report: 24 February 2025
Coroner: Richard Furniss
Coroner area: West London

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Apr 2025.

Sent to

HMP Wormwood Scrubs

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.