Gareth Chumber-Kelly

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Independent investigation into
the death of Mr Gareth
Chumber-Kelly,
a prisoner at HMP Pentonville,
on 17 July 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist HM Prison and Probation Service in ensuring the standard of
care received by those within service remit is appropriate, our recommendations should be
focused, evidenced and viable. This is especially the case if there is evidence of systemic
failure.
Mr Gareth Chumber-Kelly was found hanged in his cell at HMP Pentonville on 17 July
2023. He was 33 years old. I offer my condolences to his family and friends.
Mr Chumber-Kelly died five days after he arrived at Pentonville. He had several significant
risk factors for suicide and self-harm and had been assessed at court as presenting a risk
of suicide. Although prison and healthcare staff received information about his risk, they
did not review it. This delayed the implementation and quality of suicide and self-harm
prevention procedures (known as ACCT).
The management of ACCT procedures, once opened, was poor. Mr Chumber-Kelly’s
ACCT documentation lacked detail and was incomplete. Healthcare staff did not contribute
to his first case review, and staff misjudged his risk of suicide and self-harm.
Mr Chumber-Kelly was not given access to a phone the weekend he arrived at Pentonville
and he had not been given a prison phone account before his death. I am increasingly
concerned about the operation of prison phone accounts – both the lack of parity with
contracts for those in the community and that too little priority is given to promptly ensuring
prisoners have the ability to phone family and friends, particularly at times of crisis.
The emergency response when Mr Chumber-Kelly was found was delayed, chaotic and
lacked leadership.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman July 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. On 13 July 2023, Mr Gareth Chumber-Kelly was remanded to HMP Pentonville,
charged with attempted robbery and possession of an imitation firearm.
2. While Mr Chumber-Kelly was at court, a healthcare support worker from the Police
and Court Liaison and Diversion Service (PCLDS) reviewed him and noted in his
person escort record (PER) that he said he would kill himself if he went to prison.
She completed a suicide and self-harm warning form and emailed the prison’s
mental health team.
3. However, when Mr Chumber-Kelly arrived at Pentonville, a reception supervising
officer (SO) signed to say he had reviewed the PER and that there was nothing to
indicate a risk of suicide or self-harm. A nurse screened him but did not have
access to the email, PER or the suicide and self-harm warning form.
4. An officer conducted Mr Chumber-Kelly’s first night interview but Mr Chumber-Kelly
was not given a prison phone account so he could not call his family.
5. On 14 July, healthcare staff discussed Mr Chumber-Kelly at a referrals meeting. No
one from the mental health team attended.
6. Later that day, Mr Chumber-Kelly made a cut to his arm as he felt frustrated about
not being able to tell his family he was in prison. Prison staff started suicide and
self-harm monitoring, known as ACCT, and an officer arranged for Mr Chumber-
Kelly to phone his father.
7. On 15 July, an SO conducted a first ACCT case review. The SO recorded that Mr
Chumber-Kelly said he felt better having had contact with his family.
8. At around 12.30pm on 17 July, Mr Chumber-Kelly’s cellmate found him hanging
from a ligature and pressed the emergency cell bell. An officer attended and
radioed a medical emergency code blue at 12.34pm before going into the cell and
cutting the ligature. Additional prison staff arrived but did not start cardiopulmonary
resuscitation (CPR).
9. An emergency response nurse initially went to the wrong cell having been given
incorrect information. While on her way to the correct cell, she saw an officer
escorting a prisoner away from the cell and cancelled the code blue as she thought
the incident had been addressed. After noticing that officers continued to gather
outside that cell, she went to the cell and saw Mr Chumber-Kelly lying on the floor.
She reinstated the code blue and started CPR at 12.42pm.
10. At 1.31pm, paramedics took Mr Chumber-Kelly to University College Hospital,
London, where staff pronounced life extinct.
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Findings
Identifying and managing the risk of suicide and self-harm
11. Staff did not identify the information about Mr Chumber-Kelly’s heightened risk of
suicide as set out in his PER, suicide and self-harm warning form and the email
from the liaison and diversion team and therefore missed an opportunity to start
suicide and self-harm procedures earlier.
12. Aspects of Mr Chumber-Kelly’s ACCT document were incomplete and aspects of
the process were not managed well or in line with national policy. Staff failed to
assess Mr Chumber-Kelly’s risk to himself accurately at the first case review. Had
they considered all the risk information available, they might have assessed him as
at higher risk of suicide and self-harm and increased the protective measures.
PIN phone access
1. Mr Chumber-Kelly had not been set up with a prison phone account by the time he
died, which meant he could not freely contact his family for support at a time of
heightened vulnerability. While Mr Chumber-Kelly was allowed to briefly phone his
father, we are concerned that procedures at Pentonville, and across the prison
estate, do not allow for prisoners to be allocated a prison phone account at
weekends, or with sufficient priority on their arrival.
Emergency response
13. The emergency response was chaotic and the clinical reviewer noted the lack of
leadership. The sequence of events led to a delay of around seven minutes before
control room staff called for an ambulance.
14. While we recognise the distress and shock at finding Mr Chumber-Kelly hanging,
prison staff should have started CPR immediately but instead waited for healthcare
staff.
Clinical care
15. The clinical reviewer found that the care Mr Chumber-Kelly received at Pentonville
was not equivalent to that which he could have expected in the community.
16. The clinical reviewer considered that the prison’s mental health team should have
seen and actioned PCLDS’ email on 13 July and PCLDS should have told the
mental health team by phone. She also considered that healthcare staff failed to
take into account all Mr Chumber-Kelly’s risk factors and a member of the mental
health team should have attended the referrals meeting on 14 July.
Recommendations
• The Governor and Head of Healthcare should review the training for reception and
induction staff to ensure they understand how to identify prisoners at risk of suicide
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and self-harm, including that all relevant risk information, including the PER, is
properly shared and examined as part of the reception/first night process.
• The Director General of HMPPS should review the current process for and priority
given to setting up prison phone accounts for newly arrived prisoners (both from
court and on transfer) to ensure that they can call family and friends without delay.
• The Head of Healthcare should ensure that healthcare staff are fully prepared to
effectively manage emergency response situations.
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The Investigation Process
17. HMPPS notified us of Mr Chumber-Kelly’s death on 17 July 2023.
18. The investigator issued notices to staff and prisoners at HMP Pentonville informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
19. The investigator obtained copies of relevant extracts from Mr Chumber-Kelly’s
prison and medical records.
20. The investigator interviewed five members of staff at Pentonville between 21
September and 9 October 2023. He also interviewed three members of staff by
video conference and one by telephone between 2 and 3 October.
21. NHS England (NHSE) commissioned a clinical reviewer to review Mr Chumber-
Kelly’s clinical care at the prison. The investigator and clinical reviewer jointly
interviewed healthcare staff.
22. We informed HM Coroner for Inner North London of the investigation. She gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
23. Our investigation was suspended between December 2023 and 10 January 2025,
while waited for the post-mortem report.
24. The Ombudsman’s office contacted Mr Chumber-Kelly’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Chumber-Kelly’s mother asked:
• why staff failed to identify his risks of suicide and self-harm;
• what safeguarding procedures were in place; and
• if he should have been under constant supervision.
We have addressed these concerns in this report.
25. The solicitor representing Mr Chumber-Kelly’s family received a copy of the initial
report. They did not raise any further issues, or comment on the factual accuracy of
the report.
26. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Pentonville
27. HMP Pentonville is a local prison in London. The prison primarily serves the courts
of north and east London. Practice Plus Group, in partnership with Enfield and
Haringey Mental Health Trust, provides healthcare services.
28. HM Inspectorate of Prison
29. HM Inspectorate of Prisons (HMIP) carried out an unannounced inspection of
Pentonville in July 2022. Inspectors found that support for prisoners in crisis and
those subject to ACCT monitoring was not good enough. Few prisoners who were
monitored under ACCT procedures reported that they had felt cared for. Inspectors
noted that while ACCT case reviews were detailed, associated caremaps were
often incomplete or not used effectively. They also found that there was insufficient
leadership and oversight of suicide and self-harm prevention work. Inspectors also
noted that the Pentonville’s reception area was bleak and needed refurbishment.
They found that prisoners could spend hours waiting in reception and observed
instances of officers being impatient and unwelcoming.
30. In April 2023, inspectors returned to Pentonville to conduct an independent review
of progress. They found that governance of work to prevent suicide and self-harm
had improved. Leaders had implemented a single case manager model to improve
the quality and consistency of the ACCT process but the quality of documentation
was still not good enough. Inspectors also noted that although the reception area
and first night centre had been improved, the approach staff took to provide basic
items for daily living was inconsistent.
Independent Monitoring Board
31. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 March 2024, the IMB reported
that there had been positive improvements to reception and early days processes.
However, they also noted that the quality of ACCT documents remained inadequate
and that the safer custody department struggled to fulfil its remit due to staffing
shortages and changes to management.
Previous deaths at HMP Pentonville
32. Mr Chumber-Kelly was the ninth prisoner to die at Pentonville since July 2020. Of
the previous deaths, four were from natural causes, three were self-inflicted and
one was drug related. To the end of February 2025, there have been four deaths
since, two self-inflicted, one drug related and one from natural causes.
33. In our previous investigations into self-inflicted deaths at Pentonville we identified
concerns with the ACCT process. It is disappointing that we have found similar
issues in this investigation.
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Assessment, Care in Custody and Teamwork
34. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multi-disciplinary review meetings involving the prisoner.
35. As part of the process, support actions are put in place. The ACCT plan should not
be closed until all the support actions have been completed. All decisions made as
part of the ACCT process and any relevant observations about the prisoner should
be written in the ACCT booklet, which accompanies the prisoner as they move
around the prison. Guidance on ACCT procedures was set out in Prison Service
Instruction (PSI) 64/2011 at the time of Mr Chumber-Kelly’s death. It has since been
replaced by the Prison Safety Policy Framework.
Prison phone accounts
36. In public sector prisons in England and Wales, prisoners are given an eight-digit
personal identification number that enables them to make calls to certain agreed
numbers, and this account remains with them for the duration of their time in prison.
The prison phone system does not accept incoming calls.
37. On reception into prison, PSI 49/2011 on prisoner communication services states
that governors must have local arrangements in place to allow a call to be made in
the first 24 hours. For a prisoner to make a call, their personal phone account must
have been set up and credited with funds. A call made in reception or in the first
night accommodation can be funded in two ways:
• using a generic account, pre-funded with credits which are paid for from public
funds to enable prisoners to make a short call;
• after the prisoner has signed a form agreeing to the terms and conditions of the
use of the prison phone system and having funds credited to the account.
38. Prison administrators are generally responsible setting up a prisoner’s phone
account after he has signed the relevant form. They do not tend to work at
weekends so if a prisoner arrives on a Friday, there is often a delay.
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Key Events
13 July 2023
39. On 13 July 2023, Mr Gareth Chumber-Kelly was remanded to prison, charged with
attempted robbery and possession of an imitation firearm. He had a history of
depression and was prescribed methadone to treat opiate withdrawal.
40. At 11.28am, while Mr Chumber-Kelly was at court, a healthcare support worker
from the Police and Court Liaison and Diversion Service (PCLDS), reviewed him.
She noted that Mr Chumber-Kelly had attempted suicide in the past and said he
would kill himself if he went to prison. She completed a suicide and self-harm
warning form to alert court, escort and prison staff to his risk.
41. At 3.45pm, the healthcare support worker uploaded the warning form to Mr
Chumber-Kelly’s electronic medical record. Minutes later, she emailed HMP
Pentonville’s mental health team generic email address, highlighting his risk. There
is no evidence that this email was picked up and actioned by anyone in the mental
health team. At interview, the Head of Healthcare, told us that there was also an
expectation that PCLDS staff phone the prison’s mental health team to pass on high
risk information but this did not happen.
42. At 4.20pm, Mr Chumber-Kelly arrived at Pentonville and a Supervising Officer (SO)
booked him in. The SO signed to say that he had reviewed the digital Person Escort
Record (PER which accompanies prisoners on all journeys between police stations,
courts and prisons to communicate risk factors) and there was nothing to indicate a
risk of suicide or self-harm. However, the PER noted that Mr Chumber-Kelly had a
suicide and self-harm warning in place and a history of depression and self-harm in
prison.
43. At 4.54pm, an officer recorded in Mr Chumber-Kelly’s electronic prison record that
she had conducted his first night interview. She noted that he told her that he had
been to Pentonville before, around five years previously, and although he appeared
to be detoxing, he answered most of her questions. There is no evidence that staff
gave him a prison phone account so he could call his family.
44. At 4.56pm, a nurse completed Mr Chumber-Kelly’s initial reception health screen
and noted that he had not reported any thoughts of suicide or self-harm. There is no
record that the nurse saw the PER or suicide and self-harm warning form and no
one from the mental health team had read the warning email from the healthcare
support worker. A nurse noted that Mr Chumber-Kelly reported a history of self-
harm, depression, personality disorder and illicit drug use. The nurse tested Mr
Chumber-Kelly’s urine for illicit drugs and completed a clinical opiate withdrawal
scale (COWS) assessment, scoring Mr Chumber-Kelly 12 (mild withdrawal). He
also referred him to the health and wellbeing team meeting (a multidisciplinary
meeting that screens prisoners to identify what support services they may need).
45. At 5.34pm, prison staff moved Mr Chumber-Kelly to a shared cell on A Wing which,
at the time, was the prison’s early days in custody unit.
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46. At 6.01pm, a GP, reviewed Mr Chumber-Kelly’s drug test result and noted that he
had tested positive for cocaine, opiates and cannabis. He prescribed several
medications, including metoclopramide (to treat nausea and vomiting) and
methadone (to treat opiate withdrawal).
14 July
47. At around 8.27am, a nurse who was, a non-medical prescriber, reviewed Mr
Chumber-Kelly and recorded that he had described his mood as “good” and denied
thoughts of suicide or self-harm. She completed a COWS assessment and scored
him 16 (moderate withdrawal risk). She agreed to increase his dose of methadone
slowly and referred him to the prison’s substance misuse team.
48. At 9.34am, a pharmacy technician, reviewed Mr Chumber-Kelly’s summary care
record (a national electronic database that holds important patient information) and
confirmed that, in the community, Mr Kelly was prescribed mirtazapine (an
antidepressant). The nurse subsequently prescribed the medication.
49. At 11.32am, a nurse recorded that staff discussed Mr Chumber-Kelly at a health
and wellbeing team referrals meeting. Attendees agreed to offer him psychological
therapy, group work and substance misuse intervention. No one from the mental
health team attended, although they were supposed to. There is also no record that
the staff present at the meeting had any knowledge of the concerns outlined in the
suicide and self-harm warning form, PER and email from the healthcare support
worker.
50. At 11.30am, Mr Chumber-Kelly pressed his emergency call bell. An officer
responded and saw that he had made a cut to his left arm, using a broken mirror.
She asked for assistance and healthcare staff attended.A prison paramedic,
recorded in Mr Chumber-Kelly’s medical record that two nurses were tending to Mr
Chumber-Kelly when he arrived and that he said he had cut himself out of
frustration as he was unable to phone his family to tell them he was in prison.
51. At 11.39am, Mr Kelly was moved to a shared cell on F Wing, which, at the time,
was the prison’s integrated drug treatment system unit.
52. At 11.47am, an officer started suicide and self-harm monitoring procedures, known
as ACCT. She noted that Mr Kelly had cut his left arm with a broken mirror but did
not provide any additional information.
53. A short while later, an officer conducted Mr Chumber-Kelly’s ACCT assessment. He
noted that Mr Chumber-Kelly said it was his first time in prison for five years, he was
terrified about the prospect of receiving a long sentence, was worried about his
partner not knowing where he was and that his children may be taken into care. He
also recorded that Mr Chumber-Kelly had a history of suicidal thoughts and self-
harm. There is no evidence that the officer knew any of the risk information in Mr
Chumber-Kelly’s PER, suicide and self-harm warning form or the email to the
mental health team.
54. At 1.55pm, the officer noted that he had phoned Mr Chumber-Kelly’s partner to tell
her that he was in prison but did not get an answer. At interview, he told the
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investigator that he subsequently phoned Mr Chumber-Kelly’s father and allowed
Mr Chumber-Kelly to speak to him and let him know he was at Pentonville.
55. At 2.08pm, a SO completed an ACCT immediate action plan. (Prison Service policy
states that the immediate action plan should be completed within one hour of the
concern form being completed and before the ACCT assessment.) He recorded
‘yes’ next to the questions: ‘Would a call to family or friends help?’ and ‘Do they
have phone credit?’ Mr Chumber-Kelly did not have any phone credit.
15 and 16 July
56. At 11.30am on 15 July, a SO conducted a first ACCT case review and noted that
the paramedic attended. However, the paramedic told the investigator that he did
not attend or contribute to the review. The SO recorded that Mr Chumber-Kelly said
he harmed himself because he was not given a prison phone account or welfare
call before he was moved to F Wing but that he felt better as he had since been in
contact with his family and solicitor (according to records provided, Mr Chumber-
Kelly did not have a prison phone account set up before he died and so we do not
know if or how he called his solicitor). He added that Mr Chumber-Kelly did not
report any thoughts of suicide or self-harm but he decided to continue ACCT
monitoring, with an observation requirement of one an hour. He scheduled a review
for 24 July but did not add any actions to the care plan. Again, there is no evidence
that the ACCT review was informed by information on the PER or in Mr Chumber-
Kelly’s medical record.
57. At 12.32pm, prison phone records show that Mr Kelly dialled for a balance request
and was notified that he had no money on his account.
58. On 16 July, in the morning record of conversation section of the ACCT document,
An officer noted that Mr Chumber-Kelly said he was upset as he did not believe he
should be in prison. In the afternoon summary section, staff noted that Mr Chumber-
Kelly left his cell for association and interacted with other prisoners.
Events of 17 July
59. Shortly after starting work at around 6.45am, a SO, who was tasked with managing
F Wing, told the investigator that he found out he had only four officers detailed to
work on the wing instead of nine. He said this was due to staff shortages and, in line
with the regime management plan, the wing was placed on lockdown meaning that
staff only unlocked prisoners for controlled medication and healthcare
appointments.
60. Mr Chumber-Kelly’s cellmate, said in his police statement that he woke up to the
sound of abnormal breathing between 7.00am and 9.00am. He said that he saw Mr
Chumber-Kelly standing on top of the pipes at back of the cell with a ligature around
his neck and attached to the window bars. He said that he asked Mr Chumber-
Kelly, “What are you doing, stupid?” Mr Chumber-Kelly told him that he was worried
about getting a sentence of eight to ten years. The cellmate said that they spoke for
30 to 45 minutes and that Mr Chumber-Kelly seemed a lot calmer afterwards. He
added that he did not report it to staff as similar things happened all the time in
prison. He said that the ligature remained attached to the window bars.
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61. At around 10.30am, an officer unlocked Mr Chumber-Kelly so that he could go to a
substance misuse review. A nurse increased his methadone prescription and noted
that he did not report any thoughts of suicide or self-harm. When Mr Chumber-Kelly
returned, a SO locked him in his cell. At interview, he said that he remembered Mr
Chumber-Kelly looking a bit down but did not think too much of it as it was a
detoxification wing and lots of prisoners looked down when stopping using drugs.
62. At 11.33am, an officer conducted an ACCT check and spoke to Mr Chumber-Kelly.
In the record of morning conversation section of the ACCT, she recorded that he
was due to have a bail hearing and was still waiting for staff to apply his phone
credit. At interview, she added that he also told her that he got emergency phone
credit in reception but another prisoner had used it (we have not been able to
corroborate this information).
63. At around 12.00pm, the officer conducted a roll check. At interview, he told us that
he saw Mr Chumber-Kelly sitting on a chair in the corner of the cell. He added that
there was nothing unusual about him and nothing was attached to the window.
64. The cellmate said in his police statement that he woke up at about 12.30pm and
saw Mr Chumber-Kelly hanging from a ligature. He said that he asked Mr Chumber-
Kelly if he was okay but did not get a response. He then tried to lift him up before
lowering him down gently and pressing the cell’s emergency call bell.
65. At 12.34pm, cell bell records show that Mr Chumber-Kelly’s cell bell activated. At
12.35pm, an officer made her way to the cell and looked through the observation
panel on the cell door. She saw Mr Chumber-Kelly hanging by a ligature attached to
the window. At 12.37pm, she radioed a medical emergency code blue (which
indicates that a prisoner is unconscious or has breathing difficulties and instructs
staff in the control room to call for an ambulance), before going into the cell and
cutting the ligature. (She gave her location as the third floor but Mr Chumber-Kelly’s
cell was on the second floor.)
66. Shortly afterwards, and an officer arrived. They helped to lie Mr Kelly on the ground
but while doing so, saw that one of his legs was stuck behind the pipes at the back
of the cell. They did not start cardiopulmonary resuscitation (CPR) and waited for
healthcare staff to arrive.
67. In the meantime, a nurse, who was already on the third floor, made her way to the
landing. She could not see anyone, so she radioed for clarification and staff told her
that the incident was on the second floor. At interview, she told us that as she made
her way to Mr Chumber-Kelly’s cell, she came across an officer walking along the
landing with a prisoner (his cellmate). She said that she asked the prisoner if he
was okay and that the officer replied, saying, “He’s fine”. Assuming, in error, that the
code blue was for that prisoner, she radioed the control room and asked them to
cancel the code blue.
68. A nurse told us that she noticed that officers continued to gather outside Mr
Chumber-Kelly’s cell and she made her way there. When she arrived at 12.41pm,
she saw Mr Chumber-Kelly on the floor and reinstated the code blue. She said that
she asked officers to move him out of the cell but his leg remained stuck behind the
pipes. She established an airway and started CPR at 12.42pm. At 12.44pm, staff
manged to free his leg and moved him onto the landing for easier access.
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69. The prison’s ambulance order form shows that an ambulance arrived at the prison
at 12.47pm, and that paramedics reached Mr Chumber-Kelly at 12.50pm.
Paramedics led resuscitation efforts, supported by prison and healthcare staff. At
1.31pm, paramedics took Mr Chumber-Kelly to University College Hospital, London.
At 1.57pm, a hospital doctor pronounced life extinct.
Contact with Mr Chumber-Kelly’s family
70. At 1.57pm, the prison appointed a safer custody hub manager, as the family liaison
officer (FLO). At 2.45pm, the FLO established that Mr Chumber-Kelly had identified
his partner as his next of kin, but following police checks, it was deemed unsuitable
for staff to visit her address.
71. At 3.00pm, the FLO recorded that Mr Chumber-Kelly had recently spoken to his
father on the phone and his address was assessed as suitable to visit. As he lived
in Suffolk, the Head of Safer Custody asked HMP Highdown (which was
geographically closer) if they could send a family liaison officer but they were
unable to assist. At 4.00pm, , the prison’s police liaison officer contacted Suffolk
Police to ask for assistance. It is unknown when or whether they responded to her
request.
72. At 5.45pm, the FLO spoke to the then Governor, who agreed that they could break
the news by phone to avoid the family finding out from other sources. At 6.00pm,
She phoned Mr Chumber-Kelly’s father and broke the news. She confirmed that he
had support and arranged to visit him the following day. She also notified Mr
Chumber-Kelly’s partner.
73. On 18 July, the FLO and an officer visited Mr Chumber-Kelly’s father at his home
address to offer support and explain the next steps.
74. On 19 July, the FLO contacted Mr Chumber-Kelly’s mother following a request from
his partner. They spoke at length and she offered support.
75. The FLO continued to offer support to Mr Chumber-Kelly’s family until his funeral,
which took place on 15 August. The prison contributed towards the cost of the
funeral in line with national policy.
Support for prisoners and staff
76. After Mr Chumber-Kelly’s death, the Governor debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
77. The prison posted notices informing other prisoners of Mr Chumber-Kelly’s death
and offering support. Staff reviewed all prisoners assessed as at risk of suicide or
self-harm in case they had been adversely affected by Mr Chumber-Kelly’s death.
Post-mortem report
78. A post-mortem examination confirmed that Mr Chumber-Kelly died of suspension.
Toxicology tests found therapeutic levels of mirtazapine and methadone, low levels
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of morphine (possibly linked to non-recent heroin use) and cannabis. The
toxicologist was unable to determine when Mr Chumber-Kelly used cannabis but
noted that it could persist in the body for a considerable length of time.
Events after Mr Kelly’s death
79. On 18 July, police officers searched Mr Chumber-Kelly’s cell and found a note
tucked in a book that his cellmate confirmed he had not written. In the note, Mr
Chumber-Kelly said that he was stuck in his cell with no food, no cigarettes and no
drugs. He said that he had been trying to go to church to pray but staff would not let
him because the wing was locked down. He added that he needed to see his friend
as he owed him money.
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Findings
Assessing and managing the risk of suicide and self-harm
80. PSI 64/2011, which governed suicide and self-harm prevention procedures at the
time of Mr Chumber-Kelly’s death (since replaced by the Prison Safety Policy
Framework), required all staff who have contact with prisoners to be aware of the
risk factors and triggers that might increase the risk of suicide and self-harm and
take appropriate action. Despite recorded information, staff at Pentonville failed to
identify that Mr Chumber-Kelly was at risk when he arrived and did not begin ACCT
procedures to support him. They later began ACCT procedures when he harmed
himself but we have some concerns about the management of the process.
Reception screening
81. Mr Chumber-Kelly had significant risk factors for suicide and self-harm when he
arrived at Pentonville. He had not been in prison for five years. He was charged
with serious offences, he was likely to receive a long sentence if found guilty and he
was worried about what would happen to his children. He had a history of
substance misuse, depression, suicide attempts and self-harm and had said he
would kill himself if he went to prison. Evidence tells us that prisoners are also at
increased risk of suicide and self-harm in their first days in custody.
82. Although Mr Chumber-Kelly’s PER and suicide and self-harm warning form clearly
highlighted these risk factors, a SO signed to say that Mr Chumber-Kelly did not
have any suicide or self-harm markers and we conclude that he did not properly
review the documents.
83. The prison could not provide us with a copy of the first night centre documentation
so we could not confirm its completion. An officer’s entry in Mr Chumber-Kelly’s
prison record indicates that a first night interview was conducted but there was no
reference to Mr Chumber-Kelly’s risk of suicide or self-harm, or to information in the
suicide and self-harm warning form or PER.
84. A nurse did not assess Mr Chumber-Kelly as presenting a risk of suicide or self-
harm. He told the investigator that he routinely checked the relevant part of a
prisoner’s medical record but did not recall seeing a suicide and self-harm warning
form. He also said that he did not see the PER as it was digitised and there was an
ongoing issue with healthcare staff not having access to them. Although PCLDS
colleagues had emailed the mental health team in advance of Mr Chumber-Kelly’s
arrival to alert them to his risk, there is no evidence that anyone had read the email
or taken any action to share the information.
85. The process for identifying Mr Chumber-Kelly’s risk before he arrived at Pentonville
worked well, however, evident weaknesses in the reception process meant that
staff assessing him when he arrived in prison missed the information. Had they
seen it, they might have begun ACCT procedures at an earlier stage.
86. We asked the prison whether there were processes in place to ensure that
reception staff did not miss relevant risk information in the PER and any suicide and
self-harm warning form. They explained the current process but we are not
convinced that it is sufficiently robust. We make the following recommendation:
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The Governor and Head of Healthcare should review the training for reception
and induction staff to ensure they understand how to identify prisoners at
risk of suicide and self-harm, including that all relevant risk information,
including the PER, is properly shared and examined as part of the
reception/first night process.
ACCT procedures from 14 July
87. On 14 July, Mr Chumber-Kelly made a cut to his arm and staff began ACCT
procedures. Mr Chumber-Kelly was still subject to ACCT procedures when he died.
88. Generally, we found Mr Chumber-Kelly’s ACCT to contain little detail or information
to help staff assess the severity of his risk or record how they planned to support
him. The record of assessment did not record sufficient detail about the nature of Mr
Chumber-Kelly’s concerns or background information about his risk (other than that
he had not been in prison for five years). Despite Mr Chumber-Kelly only having
been at Pentonville for one day when ACCT procedures were started, there is no
evidence that staff referred to the PER, suicide and self-harm warning form or
gathered relevant information from his medical record.
89. No one from the healthcare team attended Mr Chumber-Kelly’s first ACCT review,
contrary to national policy, and a SO did not note any support actions in the care
plan. A SO set the observation level at one an hour, and broadly, staff conducted
the checks appropriately.
90. Overall, we consider that the ACCT procedures provided a superficial level of
support to Mr Chumber-Kelly, perhaps appropriate to the risk apparently presented
by his behaviour and presentation on 14 July but not when the information about
the severity of his risk noted in the PER, suicide and self-harm warning form and
email from PCLDS are considered.
91. Several staff involved in Mr Chumber-Kelly’s ACCT told us that time pressures and
staff shortages had negatively impacted their ability to complete the ACCT
processes properly.
92. The then Head of Safety, told us that he had implemented a quality assurance
process to drive up the quality of ACCT procedures at Pentonville. Clearly, there
were issues with the quality of Mr Chumber-Kelly’s ACCT. The Governor will want
to consider whether the existing quality assurance process is robust enough to have
identified and addressed these issues.
Prison phone access
93. Mr Chumber-Kelly did not use his prison phone account to make a phone call after
he arrived at Pentonville (although staff facilitated one call to his father). PSI
07/2015 on early days in custody requires that newly arrived prisoners are given
access to a phone to contact their legal advisor or to tell their family where they are
being held. PSI 49/2011 on prisoner communication services states that governors
must have local arrangements in place to allow a call to be made in the first 24
hours.
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94. A SO told the investigator that staff on A Wing issue the pre-funded reception
phone accounts to enable swift family contact, but Mr Chumber-Kelly was moved to
F Wing before that could happen. There is no evidence that Mr Chumber-Kelly
received an induction or signed a prison phone terms and conditions form. The
Head of Safety told us that as Mr Chumber-Kelly arrived on a Friday, his induction
would have started on the following Monday. The SO also told us that the prison
phone allocation process would have been delayed regardless, as the
administrators who set up the accounts do not work at weekends (15 to 16 July was
a weekend).
95. In the absence of reception or first night records (as the prison told us they could
not locate them), the investigator was unable to confirm the information an officer
recorded that Mr Chumber-Kelly was given a phone account in reception.
96. Mr Chumber-Kelly told staff that not being able to speak to his family was a source
of frustration and upset. Being in prison can be overwhelming and family
connections provide a sense of normalcy that can help to reduce feelings of fear
and anxiety.
97. Evidence tells us that the early days and weeks in prison increase the risk of suicide
and self-harm. We are concerned that in too many prisons, the creation of prison
phone accounts to allow prisoners to call family and friends quickly after their arrival
is not sufficiently prioritised and relies on staff who work Monday to Friday. That
such an important mitigative step is not put in place because it is the weekend is
simply unacceptable. We consider this to be a national problem requiring attention
from the most senior leaders in HMPPS. We make the following recommendation:
The Director General of HMPPS should review the current process for and
priority given to setting up prison phone accounts for newly arrived prisoners
(both from court and on transfer) to ensure that they can call family and
friends without delay.
Clinical care
98. The clinical reviewer found that the care Mr Chumber-Kelly received at Pentonville
was not equivalent to that which he could have expected in the community.
99. Prison mental health staff did not review or action the email sent by the healthcare
support worker on 13 July which provided further information about the extent of his
risk. There is no evidence that the healthcare support worker also phoned the
mental health team, which, the Head of Healthcare, told us was part of the agreed
process. Had healthcare staff reviewed the email from the healthcare support
worker, it is possible that staff would have begun ACCT procedures earlier. The
Head of Healthcare told us that she was reviewing the community pathway with the
local PCLDS team and had implemented a rota for checking the mental health
team’s generic email inbox three times a day. We therefore do not make a
recommendation about this.
100. A member of the mental health team did not attend the health and wellbeing team’s
referrals meeting on 14 July, as required. The clinical reviewer established that this
prevented discussion about the risk information from the suicide and self-harm
warning form, the PER and PCLDS. The Head of Healthcare told us that she had
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arranged supportive supervision for the nurse who did not attend. The Head of
Healthcare will nonetheless need to address the clinical reviewer’s recommendation
that a member the mental health team attends every referral meeting for the health
and wellbeing team and that relevant records are screened beforehand.
101. Healthcare staff did not demonstrate enough professional curiosity when assessing
Mr Chumber-Kelly’s risk and relied on him denying thoughts of suicide and self-
harm. The clinical reviewer considered that healthcare staff would have benefitted
from using a risk formulation approach to manage Mr Chumber-Kelly’s risk and to
supplement ACCT procedures, in line with NICE guidelines for assessing self-harm.
She made a recommendation about this which the Head of Healthcare will want to
address.
Emergency response
102. The body worn video camera footage of the emergency response showed a chaotic
scene, with staff shouting at each other. No single person led resuscitation efforts.
A nurse told us that on reflection, the shouting was not necessary but attributed it to
the shock of finding Mr Chumber-Kelly and the stress of not being able to free his
leg from behind the pipe.
103. The paramedics’ ambulance log noted that there was no obvious leadership before
their arrival and the scene was chaotic, with staff presenting as ‘flustered’. The
clinical reviewer considered that while the quality of the CPR provided was
satisfactory, the lack of leadership and the chaotic scene were concerning. While
we recognise the distressing nature of finding a prisoner hanging, healthcare staff
are responsible for taking the lead during an emergency response and
communication should be clear and concise. We make the following
recommendation:
The Head of Healthcare should ensure that healthcare staff are fully prepared
to effectively manage emergency response situations.
Governor and Head of Healthcare to note
Response following medical emergency code
104. The emergency response when Mr Chumber-Kelly was found hanged suffered from
unfortunate human errors. An officer responded promptly when she found Mr
Chumber-Kelly hanged and appropriately called a code blue but gave the wrong
landing location. As a result, a nurse initially went to the wrong cell.
105. The nurse then cancelled the code blue (and therefore the ambulance request) in
error when she wrongly assumed that the prisoner being escorted away from the
cell was the patient, and considered it was no longer a medical emergency. This
caused a delay of around seven minutes before control room staff called an
ambulance after the nurse reached Mr Chumber-Kelly’s cell and reinstated the code
blue.
106. Prison staff waited for healthcare staff to attend to start CPR. This caused a delay
of around seven minutes. A told the investigator that he simply froze and in
retrospect, knew that he should have started CPR.
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107. We do not consider that there is any recommendation we could make in these
circumstances, but the Governor will wish to consider whether there is any broader
learning about staff’s preparedness for medical emergencies.
Inquest
108. At the inquest, which took place on between 19 and 30 January 2026, the Coroner
concluded that Mr Chumber-Kelly took his own life.
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