Karim Simi

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Independent investigation into
the death of Mr Karim Simi,
on 22 July 2025, following his
release from HMP Pentonville
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
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Summary
1. 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.
2. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
3. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) 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.
4. Mr Karim Simi was found hanging in a car park on 12 July 2025, five days after his
release from HMP Pentonville. He was taken to hospital but died ten days later due
to lack of oxygen to the brain. He was 45 years old. We offer our condolences to
those who knew him.
5. Mr Simi should have been referred to community mental health services or the
homelessness outreach service before his release, but the prison’s mental health
team were unaware of his release date. Since Mr Simi’s death, Pentonville has
changed the release checklist, which now ensures that healthcare staff are notified.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Simi’s death on 1 August 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Simi’s prison and
probation records.
9. We informed HM Coroner for Camden of the investigation. She gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office contacted Mr Simi’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. He asked why Mr Simi
went to prison, how long he was there, and how long he had been released before
his death. We have addressed these questions within our report.
11. We shared our initial report with HMPPS and the prison’s healthcare provider, North
London NHS Foundation Trust. They found no factual inaccuracies.
12. We sent a copy of our initial report to Mr Simi’s brother. He did not notify us of any
factual inaccuracies.
13. We identified one factual inaccuracy and have amended this report accordingly.
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Background Information
HMP Pentonville
14. HMP Pentonville is a category B men’s prison, managed by HMPPS. It holds men
remanded by local courts, and those serving short sentences or beginning longer
sentences. North London NHS Foundation Trust provides physical and mental
healthcare services.
Probation Service
15. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Pentonville was in June 2025. Inspectors
reported that the inpatient mental health delivered particularly good levels of care.
However, there were serious failures in release planning and sentence
management. They found a lack of planning and release errors meant many
prisoners were released without proper support for housing employment or benefits.
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Key Events
Background
17. On 28 December 2024, Mr Karim Simi, whose nationality was unknown by the
Home Office but who claimed to be Palestinian, was sentenced to six months in
prison for possession of a knife. He was sent to HMP Brixton.
18. On 10 March 2025, Mr Simi was released homeless from Brixton. Because he had
no lawful basis to stay in the UK, he could not access public funds, or CAS3
accommodation (temporary accommodation for people leaving prison) or local
authority housing.
19. On 24 April, Mr Simi did not attend his probation appointment. He also failed to
attend on 29 April. Mr Simi’s community offender manager (COM) was unable to
contact him and so started recall proceedings.
20. On 21 May, Mr Simi was arrested and taken to HMP Pentonville. Mr Simi went into
RESET (where active supervision and Rehabilitation Activity Requirements (RARs)
are suspended in the final third of a Community Order or licence).
Pre-release planning
Housing
21. On 22 May, during his reception screening, Mr Simi told staff that he was homeless
and had been rough sleeping.
22. On 30 May, staff at Pentonville completed the Basic Custody Screening Tool with
him and referred him to a housing charity through Commissioned Rehabilitative
Services (CRS).
Mental health
23. On 23 May, a nurse from the mental health team assessed Mr Simi. He said he was
hearing voices, but they were “all right” at that time. He said he had no thoughts of
suicide or self‑harm. He said he had schizophrenia and was previously prescribed
olanzapine (antipsychotic medication). The nurse referred him to the Mental Health
In‑Reach Team (MHIRT) and restarted olanzapine.
24. On 17 June, staff found Mr Simi in his cell with a ligature around his neck. An officer
started suicide and self-harm prevention procedures (known as ACCT) and set
checks at one an hour.
25. At the first ACCT review later that day, Mr Simi said he had tied the ligature
because he wanted more medication and was struggling with voices. He also said
he had not been sleeping for several days. A healthcare worker noticed cuts on his
left arm. The case review team agreed to refer him to the GP for a medication
review and to continue ACCT monitoring.
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26. Later that evening, a GP reviewed Mr Simi’s medication and prescribed him
sertraline (an antidepressant) and zopiclone (medicine to aid sleep).
27. On 19 June, officers again found Mr Simi with a ligature around his neck. They
entered the cell, cut the ligature, and placed him in the recovery position.
Healthcare staff checked his airway and breathing were normal. Mr Simi then
became aggressive, so staff could not complete further observations. Officers found
two modified vapes in his cell, which suggested he had used psychoactive
substances (PS). ACCT checks continued at one an hour, and a mental health
worker reviewed him three times that day.
28. On 23 June, during a routine check, an officer saw Mr Simi tightening and loosening
a ligature around his neck. The officer removed the ligature and asked healthcare
staff to review him. Healthcare staff checked him and were content he was not
injured.
29. On 27 June, a GP reviewed Mr Simi’s mental health medication. He increased his
sertraline and noted that he was looking well.
30. On 2 July, a senior officer tried to hold an ACCT review with Mr Simi and his mental
health key worker. Mr Simi initially agreed to engage but refused once the senior
officer told him he could not give him a vape. The senior officer rescheduled the
review for the next day.
31. On 3 July, Mr Simi’s mental health key worker was unavailable, so the senior officer
asked a chaplain to attend in their place.
32. On 7 July, before release, Mr Simi had a final ACCT review with an officer in
reception. He said he was pleased to be returning home and spoke positively about
the future. He said he had no thoughts of suicide or self‑harm. MHIRT were not
aware of his release.
Substance misuse
33. At reception, Mr Simi told a healthcare worker that he had previously used cocaine
and crystal methamphetamine. He said his most recent crystal methamphetamine
use was 21 May, before his arrest.
34. On 29 May, a substance misuse service (SMS) worker spoke to Mr Simi through his
cell door. He was unable to have a full key work session with Mr Simi as officers
could not unlock the door due to staffing levels. Mr Simi said he had no current
substance misuse issues. The SMS worker warned him about bad batches of
hooch (illegally brewed alcohol) and PS reported on his wing. Mr Simi said he did
not like either and had no plans to use them.
35. On 30 May, a SMS worker had a key work session with Mr Simi. They discussed
harm reduction and how Mr Simi had taken positive steps by not using drugs since
he had entered prison. Mr Simi said he wanted to stop using crystal
methamphetamine once back in the community. The SMS worker agreed to refer
him to Change Grow Live, the community substance misuse service, for support on
release.
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36. On 20 June, a SMS worker had a key work session with Mr Simi. Mr Simi said he
had not used any substances, despite being found suspected under the influence
the day before.
37. On 1 July, Mr Simi had a SMS key work session. His key worker noted Mr Simi
looked well and felt more positive than the previous week. Mr Simi denied any
substance use and asked for information about his immigration hold.
Release from HMP Pentonville
38. Mr Simi was due to be released from Pentonville on 11 June 2025. However, due to
him being held under immigration detention powers, his release was delayed until
immigration bail was granted.
39. On 25 June, Mr Simi was allocated a new community offender manager (COM),
who was part of the RESET team.
40. On 26 June, Mr Simi’s prison offender manager (POM) told him that they were
awaiting confirmation from the Home Office on whether he would be released or
detained under immigration powers.
41. On 3 July, Mr Simi’s POM saw him on the wing. He told him that he had spoken to
the Home Office, and they had told him that they were going to come and see Mr
Simi with the paperwork for immigration bail in the next week. This meant Mr Simi
would be released into the community, pending his deportation. Mr Simi said he
was happy with the update.
42. On 7 July at 1.00pm, Mr Simi was released homeless from Pentonville on
immigration bail and licence. Mr Simi declined support with GP registration and was
given information on healthcare services. He was told his appointment with Change
Grow Live, the community substance misuse service, was on 8 July.
43. Mr Simi had no contact details, and no phone. He did not attend his initial
appointment with probation.
44. On 8 July, Mr Simi went to the probation office, but he had no appointment booked
and his COM was not in. The COM asked reception staff to tell him to return the
next day at 12.00pm, noting he had no phone.
45. The next day, Mr Simi did not attend the probation office. His COM could not send
an enforcement letter because Mr Simi had no known address.
Circumstances of Mr Simi’s death
46. On 12 July, a passer‑by found Mr Simi hanging in a car park. They called
emergency services and started CPR. After about 30 minutes, paramedics found a
pulse and intubated him. They took him to hospital for further treatment.
47. Hospital staff continued to treat Mr Simi, but they concluded he had brain damage
from which he would not recover. Doctors removed life support, and he died on 22
July.
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Post-mortem report
48. The post-mortem report concluded that Mr Simi died from hypoxic brain injury (brain
damage caused by the brain not getting enough oxygen) following successful
resuscitation from cardiac arrest, caused by suspension by ligature.
49. The toxicology report showed Mr Simi was not under the influence of drugs or
alcohol when he died. However, because he had been in hospital for ten days, it is
not possible to say whether he had taken drugs or alcohol before admission.
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Findings
Mental health
50. Mr Simi saw a mental health key worker regularly at Pentonville and had several
medication reviews with a GP to help manage his symptoms.
51. We found that staff appropriately started suicide and self-harm monitoring for Mr
Simi after he tied a ligature around his neck on 19 June. This support continued
throughout his stay at Pentonville. We consider he received a good level of mental
health support in custody.
Housing
52. Due to his immigration status, Mr Simi had no access to public funds which meant
he could not access much of the accommodation available to people leaving prison
homeless. Staff at Pentonville referred Mr Simi to a housing support charity, through
CRS. However, no housing was found for him before his release.
Substance misuse
53. When Mr Simi arrived at Pentonville, he told staff that he had a history of cocaine
and crystal methamphetamine use. He denied any use while in Pentonville and
engaged well with substance misuse key work sessions. We consider that Mr Simi
had good support with substance misuse in prison and was appropriately referred to
community substance misuse services in the community release.
Release planning
54. Mr Simi was not referred to community mental health services before his release.
The service lead for the mental health in-reach service at Pentonville told us that
the service was not aware of Mr Simi’s release date and only found out after his
release. Had they known, they would have referred him to either the community
mental health team (if he had an address) or the homelessness outreach team.
55. The Head of the Offender Management Unit (OMU) at Pentonville told us that at the
time of Mr Simi’s release, there was no formal process for OMU to inform
healthcare staff about scheduled releases. The assumption was that if a prisoner
was under the care of a healthcare team, they would have access to their release
date without being told by OMU. Since Mr Simi’s death, they have designed new
release checklists that require staff to inform healthcare staff either on the day of
release (for immediate releases), or 14 days before release (for standard releases).
56. We are satisfied that the prison has taken steps to address the issue and make no
recommendation.
Adrian Usher
Prisons and Probation Ombudsman March 2026
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Inquest
At the inquest, held on 7 July 2026, the Coroner reached a narrative conclusion:
“Mohamed Benmebarek, aka Karim Simi, died on 22 July 2025 at St Mary's Hospital,
Paddington, London from a hypoxic brain injury he suffered as a result of suspending
himself by a ligature on 12 July 2025. He had, on 7 July 2025, been released from HMP
Pentonville on immigration bail. The prison had not made the prison's mental health team
aware of his release date, such that the mental health team had not been involved in his
release planning. This meant that there was no opportunity for provision to be made for
ongoing assessment and care of Mr Benmebarek's mental health in the community.”
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