Moses Hailemichel

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Independent investigation into
the death of Mr Moses
Hailemichel, following his release
from HMP Pentonville, on 3 March
2025
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
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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 Moses Hailemichel died from suspension by ligature after he was found hanged
on 3 March 2025, following his release from HMP Pentonville six days earlier. He
was 20 years old. We offer our condolences to those who knew him.
5. The clinical reviewer concluded that the clinical care Mr Hailemichel received
leading up to his release from Pentonville was only partially equivalent to that which
he could have expected to receive in the wider community. While she found that Mr
Hailemichel received more timely and regular input from the mental health team in
prison than he could have expected in the community, she concluded that there
was a breakdown of communication between community services, healthcare and
prison teams which affected the continuity of care provision and release planning
for him.
6. We found that there was a delay in Mr Hailemichel’s sentence calculation, and he
was not allocated a Prison Offender Manager (POM) at Pentonville. When
healthcare staff contacted Mr Hailemichel’s community offender manager (COM),
he did not share important information about Mr Hailemichel’s release address and
that he was under the care of social services.
Recommendations
• The Head of Healthcare, Release and Transfer Mental Health Lead and the London
Prisons Mental Health Service Lead should:
• work with the Offender Management Unit (OMU) to ensure there is a
collaborative policy in place to support pre-release planning for short-term
sentences (of less than twelve weeks); and
• ensure that when there are urgent concerns about a prisoner following
release, onward referrals are completed urgently by telephone, where
possible, so that a full handover and context can be provided to community
services.
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• The Head of Healthcare should ensure that an interpreter is arranged for patients
who have an alert on their medical records to indicate that they need interpretation
services.
• The Head of Redbridge and Waltham Forest Probation Delivery Unit should ensure
that probation practitioners share with relevant prison and healthcare staff
safeguarding information about whether a prisoner is known to social care services.
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The Investigation Process
7. HMPPS notified us of Mr Hailemichel’s death on 18 August 2025.
8. The PPO investigator obtained copies of relevant extracts from Mr Hailemichel’s
prison and probation records.
9. NHS England commissioned an independent clinical reviewer to review Mr
Hailemichel’s clinical care at HMP Pentonville.
10. The PPO investigator and clinical reviewer interviewed two members of staff on 30
September and 14 October 2025. They also spoke to a social worker for information
purposes only on 11 November.
11. We informed HM Coroner for East London of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
12. The Ombudsman’s office contacted Mr Hailemichel’s next of kin, a friend, to explain
the investigation and to ask if he had any matters he wanted us to consider. He did
not respond to our letter.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
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Background Information
HMP Pentonville
14. HMP Pentonville is a category B prison which holds remanded and convicted male
prisoners. Practice Plus Group is the healthcare provider.
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
appropriate. 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 and July 2025.
Inspectors reported that Pentonville had failed to address the considerable backlog
in sentence calculation, which prevented effective sentence or release planning.
Some prisoners reported that they had been sentenced weeks or months earlier but
had not received their sentence calculation dates.
17. HMIP issued an Urgent Notification following this inspection. (An Urgent
Notification is the process HMIP uses to alert the Secretary of State for Justice
about significant concerns about a prison’s performance.) HMIP found that
Pentonville achieved the lowest healthy prison assessment scores for safety,
purposeful activity and preparation for release. Pentonville provided an action plan
stating that as of August 2025, additional resource had been secured to clear the
sentence calculation backlog, training had been provided to Offender Management
Unit (OMU) staff to improve their capability and competence, and a rota had been
introduced to ensure appropriate cover of the mailbox to improve timely responses
to court outcomes.
Deaths following release from prison
18. Since September 2021 to the end of January 2026, the PPO has started
investigations into nearly 300 deaths of people who die within 14 days of release
from prison. The PPO has published two learning lessons bulletins about post-
release deaths, most recently in July 2024. Our investigations highlight the acute
vulnerability of prison leavers, especially during the first few days post-release, and
indicate that prison leavers often have multiple risk factors such as mental health
and substance use issues and homelessness which further increase their
vulnerability and risk of death following release from prison.
Previous deaths following release from Pentonville
19. Mr Hailemichel was the second of three men to die within 14 days of release from
Pentonville since October 2023, and the first of two to take his own life. Although we
made no recommendations in our investigation report into the self-inflicted death
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which took place four months after Mr Hailemichel’s death, that person was also
released without a referral to community mental health services. Pentonville told us
that they had put in place a process to ensure that the mental health team is told of
the scheduled release date for a prison leaver before his release.
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Key Events
Background
20. On 29 January 2025, Mr Moses Hailemichel, an Eritrean national, was remanded to
HMP Pentonville, charged with possession of a knife in a public place. A nurse
completed his initial health screen in reception and noted that he said he had no
suicidal thoughts or mental health problems. She recorded that he needed an
interpreter but there is no evidence that one was arranged.
First release from HMP Pentonville
21. On 5 February, the healthcare team received Mr Hailemichel’s community medical
records which noted that he had a mental and behavioural disorder due to his use
of cannabinoids. They asked the mental health team to review him.
22. On 6 February, Mr Hailemichel was sentenced to four weeks in prison for malicious
wounding and other similar offences. Based on his offence type, Mr Hailemichel
had been assessed as posing a medium risk of serious harm to others.
23. On 8 February, a mental health nurse, saw Mr Hailemichel for his mental health
review. He recorded that Mr Hailemichel’s community records indicated that he was
prescribed mental health medication and had been diagnosed with a mental and
behavioural disorder but he had not been willing to engage with the community
mental health team. When the nurse visited Mr Hailemichel in his cell, he made it
clear that he did not want to be seen. The nurse offered to come back another time,
but Mr Hailemichel was adamant that he did not want to see him. The nurse left the
cell and recorded that the mental health team would nonetheless try again in due
course.
24. On 9 February, an officer was allocated as Mr Hailemichel’s Community Offender
Manager (COM). The COM told us that he did not make contact as Mr Hailemichel
was being released the following day and he expected him to attend his probation
induction appointment in the community.
25. On 10 February, a nurse who was the Early Days in Custody Mental Health Lead,
made a second attempt to complete a mental health review with Mr Hailemichel. Mr
Hailemichel shouted at her, told her to get out and was verbally aggressive and
intimidating. The nurse recorded that she was unable to complete the full
assessment due to Mr Hailemichel’s aggressive behaviour and that he may benefit
from a psychiatric review.
26. Later that day, Mr Hailemichel was released from Pentonville. He did not attend his
initial appointment with the Probation Service.
27. Mr Hailemichel was a care leaver and had a care-leaving placement arranged by
the local authority in accommodation providing semi-independent living. On 11
February, the COM telephoned Mr Hailemichel’s social worker. The social worker
told the COM that he had seen Mr Hailemichel that day and he had not mentioned
an appointment with the Probation Service. The social worker said that Mr
Hailemichel’s English was limited, and he had a history of mental health problems.
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28. The nurse emailed the COM to report concerns about Mr Hailemichel’s mental
health and that a full mental health assessment had not been completed in prison
due to his behaviour. The nurse asked the COM to consider referring Mr
Hailemichel to the community Crisis team (who provide urgent help for those in
mental health crisis) if he presented with acute mental health and behavioural
concerns.
Recall to HMP Pentonville
29. On 14 February, Mr Hailemichel was recalled to Pentonville for failing to attend his
initial appointment with the Probation Service. During his first night interview with a
member of the Safer Custody Team, Mr Hailemichel confirmed that he would speak
to staff if he felt low or had concerns and he reported no mental health concerns. A
nurse tried to complete his initial health screen in reception but Mr Hailemichel said
he did not want to be assessed. There is no indication in the medical records that
Mr Hailemichel’s need for an interpreter was identified during this admission to
Pentonville.
30. On 17 February, a multidisciplinary team meeting took place to discuss Mr
Hailemichel. It was noted that he had been diagnosed with a mental and behaviour
disorder and that there were no suicide or self-harm concerns. A nurse tried to see
Mr Hailemichel for an assessment but staff were taking him to the shower at the
time. Prison staff told her that Mr Hailemichel’s behaviour had been challenging for
the last few days, and it was unlikely that he would engage.
31. A Senior Probation Officer (SPO) told us that a sentence calculation for Mr
Hailemichel (to calculate when he should be released) took place on 18 February.
(Mr Hailemichel was to be released on 25 February.) The SPO said that there was
a delay in the sentence calculation as Pentonville was managing a backlog of
cases. He told us that following this, Mr Hailemichel should have been allocated a
Prison Offender Manager (POM). However, Pentonville have a locally agreed five
working day timescale to allocate POMs following sentence calculation and Mr
Hailemichel was to be released before this took place. A mental health team
meeting took place, and it was decided that Mr Hailemichel would be referred for
inpatient admission on the healthcare unit.
32. On 19 February, the COM responded to a nurse’s email. He said he would refer Mr
Hailemichel to Crisis after he had attended his first probation appointment after
release. The COM did not inform the nurse of Mr Hailemichel’s release address or
that he was under the care of social services in his response. The COM told us that
he did not contact Mr Hailemichel as he was only recalled to prison for a brief period
and he had received background information from the prison about Mr Hailemichel.
33. On 20 February, a nurse visited Mr Hailemichel to review his need for inpatient
admission. Mr Hailemichel was very angry, tried to attack a nurse and prison
officers had to block him. The nurse recorded that due to Mr Hailemichel’s paranoid
and guarded presentation, he needed planned intervention to reduce the risk of
harm to himself and others.
34. On 22 February, when a nurse visited him, Mr Hailemichel did not engage but
shouted at her. Although medical records state that he was awaiting inpatient
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admission, there is no indication that Mr Hailemichel was transferred to the inpatient
unit before his release.
Second release from HMP Pentonville
35. On 25 February, Mr Hailemichel was released from Pentonville to accommodation
provided by the local authority for those leaving care. He refused to take his
medication when he left the prison. He also refused to sign his licence paperwork.
The London Prisons Mental Health Service Lead told us that healthcare staff were
not aware that Mr Hailemichel was being released until they saw him in reception.
Release planning and onward referrals were therefore not completed before his
release.
36. A mental health practitioner who was the Release and Transfer Mental Health Lead
at Pentonville, emailed the COM to ask for Mr Hailemichel’s release address so that
he could be referred to community mental health services. Another probation
practitioner responded, providing Mr Hailemichel’s address as the COM was on
annual leave.
37. A nurse referred Mr Hailemichel to the community mental health team by email. An
automated out-of-office message was emailed in response which instructed that
contact should be made by telephone if the matter was urgent. This did not happen.
The community mental health team subsequently picked up the email and triaged
Mr Hailemichel’s case, with a plan to see him within two weeks. (He died before
they saw him.)
38. Mr Hailemichel did not attend his initial appointment with the Probation Service. A
letter was issued, asking for evidence of the reasons for his non-attendance and
informing him of his next appointment on 4 March. It warned that he was in breach
of his licence conditions.
Circumstances of Mr Hailemichel’s death
39. On 3 March, a resident at Mr Hailemichel’s accommodation initiated a police
welfare check as they had not heard from him for some time and were unable to
contact him. When they went into his room, the police found Mr Hailemichel hanged
in the corner of the room.
40. On 6 March, the COM received an email from Mr Hailemichel’s social worker,
saying that another resident felt unsafe as the police had come and left with a body
in a bag. Mr Hailemichel’s key worker visited the home and found no evidence of
police having been in Mr Hailemichel’s room. There was no other information to
confirm the resident’s account. Mr Hailemichel’s social worker said they would
contact the COM if they received further information.
41. On 17 March, the social worker emailed the COM and informed him that Mr
Hailemichel had apparently taken his own life. This email was not uploaded to the
Probation Service’s case management system and we do not know whether the
COM saw it.
42. Between 18 March and 24 April, the COM sent two letters to Mr Hailemichel’s
address to say that he was in breach of his licence conditions, initiating recall
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procedures and requesting a summons to court as Mr Hailemichel had failed to
attend multiple appointments.
43. On 24 April, the case administrator for London Service Centre (part of the Probation
Service) emailed the COM and told him that Mr Hailemichel had died.
Post-mortem report
44. The post-mortem report concluded that Mr Hailemichel died from suspension by
ligature.
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Findings
Risk of suicide
45. Mr Hailemichel took his own life six days after he was released from prison. He had
a history of mental health problems. During his two brief periods in custody, he did
not engage much with prison or healthcare staff and his behaviour was sometimes
challenging. While there were concerns for his mental health, he did not harm
himself or express thoughts of suicide. Other than his poor mental health, there was
little to indicate that he was at an increased risk of suicide or that he should have
been monitored under suicide and self-harm prevention procedures in prison.
Clinical findings
46. The clinical reviewer concluded that the care that Mr Hailemichel received in the
lead up to his release from Pentonville was partially of the standard reasonably
expected and was therefore equivalent to that which he could have expected to
receive in the wider community. She noted that while it was difficult to consider pre-
release planning in the context of equivalence because it is a prison-specific
process, the pre-release planning for Mr Hailemichel was not equivalent to the
expectation in comparable prison settings nationally. There was some evidence of
equivalent care, including the contact Mr Hailemichael had with the integrated
mental health hub in prison, and it is likely that he received more timely and regular
input than he could have initially expected in the community. However, the clinical
reviewer concluded that there was a breakdown of communication between
community services, healthcare and prison teams which impacted on Mr
Hailemichel’s continuity of care, release planning and the safety of his release.
Pre-release planning
47. A nurse emailed the community mental health team on 25 February. This triggered
an automated out-of-office response which instructed that the team should be
contacted by telephone if the matter was urgent. This did not happen. Although the
community mental health team subsequently picked up the message and triaged Mr
Hailemichel’s case, with a plan to see him within two weeks, he died before this
happened. The clinical reviewer concluded that the Release and Transfer Team
should have telephoned the community mental health service on receipt of the
automated out-of-office email, given the urgency indicated by Mr Hailemichel’s
presentation in prison and the need for a referral to Crisis for immediate support.
48. Neither healthcare nor prison staff were aware that Mr Hailemichel was a care
leaver and had an allocated community social worker as he had not disclosed this
information. Had they known, a multidisciplinary team (MDT) meeting could have
been held with social services before Mr Hailemichel’s release, and this would likely
have provided better release planning and continuity of care.
49. Both of Mr Hailemichel’s periods in prison were brief. Practice Plus Group have a
number of processes in place to support release and transfer processes but these
focus on a pre-release planning period of twelve weeks. While the London Prisons
Mental Health Service Lead, told us that the Offender Management Unit (OMU) give
the healthcare team a daily paper list of prisoners being released over the following
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few days, the clinical reviewer found that there was no collaborative policy in place
to support pre-release planning for shorter sentences.
50. For both periods in custody, the Release and Transfer Team within the healthcare
department were not aware that Mr Hailemichel was being released until the day of
his release. Since Mr Hailemichel’s death, all healthcare staff involved in the
release and transfer process have been given access to prison records so that they
can regularly check release dates to better support prison leavers.
51. We make the following recommendations:
The Head of Healthcare, Release and Transfer Mental Health Lead for
Pentonville and the London Prisons Mental Health Service Lead should:
• work with the Offender Management Unit (OMU) at Pentonville to
ensure there is a collaborative policy in place to support pre-release
planning for short-term sentences (of less than twelve weeks); and
• ensure that when there are urgent concerns about a prison leaver,
onward referrals are completed by telephone, where possible, so that a
full handover and context can be provided to community services.
Use of an interpreter
52. During Mr Hailemichel’s first period in custody, it was recorded in his medical
records that he needed an interpreter as his first language was not English.
However, this was not arranged for him. During his second period of custody, there
is no indication that this need was identified. This likely affected Mr Hailemichel’s
ability and willingness to engage and an interpreter would have ensured that he
understood and was able to communicate more effectively with staff. We make the
following recommendation:
The Head of Healthcare should ensure that interpreters are arranged for
patients who have an alert on their medical records to indicate that they need
interpretation services.
Allocation of a Prison Offender Manager
53. In line with HMPPS’ Offender Management in Custody (OMiC) Model, all sentenced
individuals should be allocated a Prison Offender Manager (POM) to undertake
offender management activities (which includes pre-release planning). The OMiC
Delivery Manager, told us that there was no specific timeframe for a case to be
allocated to a POM but there was an expectation that all cases are allocated as
soon as possible to avoid delays in risk assessment and sentence planning. The
OMiC process map indicates that as soon as sentence calculations have been
completed and reviewed for accuracy, the case should be allocated to a POM.
54. Mr Hailemichel was not allocated a POM during his initial admission to Pentonville
or when he was recalled. A POM might have enabled collaborative communication
between the prison, healthcare services and the COM to plan for Mr Hailemichel’s
release. This might have resulted in healthcare staff being aware of Mr
Hailemichel’s release date and address earlier. It would also have given the COM a
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designated contact in the prison to discuss Mr Hailemichel’s identified risks and
needs.
55. The SPO told us that Mr Hailemichel was not allocated a POM because there was a
delay in his sentence calculation due to a backlog, as referenced in HMIP’s recent
Urgent Notification. The Head of Offender Management Services told us that the
backlog had been cleared and that although there were a number of measures in
place to try to prevent it happening again, they were still experiencing an ongoing
backlog of more recent cases which they were working to address. He said that
they had recruited ten additional members of staff in the Offender Management Unit
(OMU).
56. Although there is no written local policy, the SPO told us that Pentonville had
agreed locally that POMs should be allocated within five working days following
sentence calculation. For both his releases, Mr Hailemichel was released within five
days of his sentence calculation and had not been allocated a POM.
57. While the delay in Mr Hailemichel’s sentence calculation resulted in him not being
allocated a POM, we recognise that Pentonville are addressing this issue.
58. We draw to the Governor’s attention that the five-day timescale to allocate a POM
may cause further delay in completing meaningful pre-release work, particularly for
those serving short sentences, and could result in more prison leavers not being
allocated a POM.
Information sharing
59. A senior probation officer told us that COMs routinely make safeguarding enquiries
to determine whether an individual is known to social care services. The COM
contacted Mr Hailemichel’s social worker on 11 February and gathered this
information.
60. When Mr Hailemichel was recalled, there is no indication that the prison or
healthcare team were aware that he was under the care of social services and was
being released to accommodation for those leaving care. In addition, social services
were not aware that Mr Hailemichel was in prison.
61. The mental health team emailed the COM on 19 February and asked him to refer
Mr Hailemichel to Crisis on release as they were concerned about his mental
health. The SPO told us that he would have expected the COM to have informed
the mental health team at this point that Mr Hailemichel was under the care of social
services. This would have enabled the healthcare team and social services to work
collaboratively to arrange appropriate support for Mr Hailemichel’s release.
Additionally, when probation staff responded to the mental health team’s email
about Mr Hailemichel’s address on 25 February, the email did not indicate that Mr
Hailemichel had a leaving care placement or that he had an allocated social worker.
62. As Mr Hailemichel did not have a POM, the COM did not have a designated contact
at the prison. However, this made it even more important for the COM to inform the
healthcare team of this information when they contacted him. We make the
following recommendation:
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The Head of Redbridge and Waltham Forest Probation Delivery Unit should
ensure that probation practitioners share with relevant prison and healthcare
staff safeguarding information, including whether a prisoner is known to
social services.
Head of Redbridge and Waltham Forest Probation Delivery Unit to note:
63. The COM was not aware that Mr Hailemichel had accommodation for those leaving
care until the day after his initial release from prison. Despite this, he had not
completed any accommodation referrals. It is fortunate that Mr Hailemichel had
other arrangements in place and was not released homeless. Taking into account
that the lack of referral in this case did not impact on Mr Hailemichel and that the
COM was not allocated as Mr Hailemichel’s COM until the day before his initial
release, we do not make a recommendation about his.
64. The COM received an email from Mr Hailemichel’s social worker on 17 March 2025
to let him know that Mr Hailemichel had died. This email was not uploaded to the
Probation Service’s case management system and we do not know whether or not
The COM saw the email. (Although we interviewed the COM, this issue was
identified subsequently by which time he was on long-term sick leave and we were
unable to confirm the position with him.) He told us at interview that the London
Service Centre notified him of Mr Hailemichel’s death on 24 April 2025, which is
when he started the process to record and review the death under supervision. This
process was delayed by over a month after Mr Hailemichel’s death, during which
time the COM issued two letters to Mr Hailemichel’s address, initiating a recall to
prison and asking for a court summons for Mr Hailemichel for breaching his licence
conditions. It is possible that he missed the email of 17 March due to human error
or oversight. On receipt of the email, the COM should have contacted the police or
the Coroner or sought advice from his line manager promptly.
Inquest
65. At an inquest held on 25 August 2026, the Coroner determined the medical cause
of death to be suspension by ligature. The jury returned a narrative conclusion,
stating that Mr Hailemichel died as a result of suicide.
Adrian Usher April 2026
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