Peter Campbell

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Peter Campbell,
a prisoner at HMP Pentonville,
on 8 October 2024
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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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 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.
Mr Peter Campbell died in hospital of pneumonia and ischaemic hypoxic brain injury
caused by a cardiac arrest following alleged drug use on 8 October 2024, having been
found unresponsive in his cell on 3 October at HMP Pentonville. He was 36 years old. I
offer my condolences to Mr Campbell’s family and friends.
Mr Campbell had a history of mental illness and substance misuse, and both were features
of his last period in prison. Although Mr Campbell received frequent and considered care
from his mental health in-reach worker, opportunities were missed across the board to
help Mr Campbell, particularly to act on some intelligence reports and safeguarding
referrals.
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 December 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. On 9 March, Mr Peter Campbell was remanded to HMP Wormwood Scrubs
charged with burglary. On 9 April, he transferred to HMP Pentonville.
2. Mr Campbell had a history of poor mental health, including a diagnosis of
schizophrenia, and drug misuse. He also had a history of attempted suicide and
self-harm.
3. On arrival at Pentonville, he was assessed by the mental health team and taken
onto their caseload. His in-reach key worker saw him frequently and kept detailed
records of their interactions. Mr Campbell did not wish to work with the prison’s
psychosocial substance misuse team, Phoenix Futures.
4. On 18 April, staff started suicide and self-harm prevention measures (known as
ACCT), after Mr Campbell started eating his own faeces. A few days later, Mr
Campbell was found under the influence of substances and his involvement with
psychoactive substances (PS) (both using substances and moving them around the
prison) continued. Staff submitted several intelligence reports, but Mr Campbell’s
cell was only searched once.
5. In June, staff closed Mr Campbell’s ACCT because he seemed more stable.
6. By July, Mr Campbell’s PS use had increased again and his behaviour deteriorated.
7. On 18 and 19 September, staff referred Mr Campbell to the safeguarding team
because they were concerned about his presentation, PS addiction and that he was
possibly being used by other prisoners to test PS. The safeguarding team did not
meet with Mr Campbell as they should have done.
8. Also on 19 September, a consultant psychiatrist assessed Mr Campbell, but did not
assess him as acutely unwell enough for a hospital transfer.
9. On 3 October, an officer found Mr Campbell unresponsive in his cell having
apparently taken PS. The officer radioed a medical emergency code and custodial
and healthcare staff attended. Paramedics arrived and took Mr Campbell to
hospital, but he did not recover.
10. On 8 October, Mr Campbell died.
11. The post-mortem report noted Mr Campbell’s cause of death to be pneumonia and
ischaemic hypoxic brain injury caused by a cardiac arrest following alleged use of
synthetic cannabis.
Findings
12. Mr Campbell had a history of mental illness and substance misuse, and both were
features of his last period in prison custody. Mr Campbell received frequent and
considered care from his mental health in-reach worker, but staff missed
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opportunities to help Mr Campbell further, particularly to act on some intelligence
reports and safeguarding referrals.
13. Mr Campbell was able to access illicit drugs with apparent ease at Pentonville.
There was intelligence to suggest that prisoners, including Mr Campbell, were
distributing and using illicit substances in the prison and that he was being used as
a guinea pig to test new PS that came into prison. While Mr Campbell was offered
appropriate support from the substance misuse team, he did not always fully
engage.
14. Pentonville’s interim drug strategy is clear and addresses the current trends and
access routes for PS into the prison. However, staff did not act upon all of the
intelligence which indicated Mr Campbell was involved in the illicit drug culture at
the prison and staff completed only one intelligence-led search of his cell.
15. The clinical reviewer concluded that the healthcare Mr Campbell received at
Pentonville was equivalent to what he could have expected to receive in the
community.
Recommendations
• The Governor should ensure that ACCT care plan actions are quality assured
regularly to satisfy himself that all actions have been fully completed.
• The Head of Safety should ensure members of the team keep SIM meeting minutes
and that, as far as is reasonably possible, there is adequate cover when staff are on
leave to deal with safeguarding referrals.
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The Investigation Process
16. HMPPS notified us of Mr Campbell’s death on 8 October 2024.
17. The investigator issued notices to staff and prisoners at HMP Pentonville informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
18. The investigator visited Pentonville on 14 October. She obtained copies of relevant
extracts from Mr Campbell’s prison and medical records.
19. The investigator interviewed ten members of staff at Pentonville and by video
conferencing between December 2024 and January 2025.
20. NHS England commissioned a clinical reviewer to review Mr Campbell’s clinical
care at the prison. The investigator and the clinical reviewer carried out joint
interviews.
21. We informed HM Coroner for London Inner North of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
22. The Ombudsman’s office contacted Mr Campbell’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Campbell’s family wanted to know if Mr Campbell’s mental health was appropriately
cared for and if his suicide risk was monitored. We have answered these questions
in the clinical review and in our report.
23. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is an additional
annex to this report.
24. We also shared the report with Mr Campbell’s family. They did not make any
comments.
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Background Information
HMP Pentonville
25. HMP Pentonville is a local prison in London that primarily serves the courts of north
and east London. Practice Plus Group, in partnership with Barnet, Enfield and
Haringey Mental Health Trust, provides healthcare services.
HM Inspectorate of Prisons
26. The most recent full inspection of HMP Pentonville was in July 2022. Inspectors
highlighted eight priority concerns, including that the prison was severely
overcrowded and could not safely or decently care for the number of prisoners it
was required to hold.
27. HMIP returned to Pentonville in April 2023 to conduct an independent review of
progress. Inspectors identified reasonable progress on five of their key concerns but
were disappointed to find that the prison was even more overcrowded than in 2022.
Improvements had been made to support prisoners in the early days of custody and
most of the shortfalls in primary care services had been addressed. Although
staffing levels had improved, there was still pressure on the daily management of
the regime and time out of cell was limited. The rate of self-harm at Pentonville had
continued to reduce and was the lowest among all reception prisons.
Independent Monitoring Board
28. 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 2023, the IMB reported
the key work scheme was barely operating due to staff shortages and the priority of
security operations. Regular safety meetings were held which was a significant
improvement and were attended by prisoner representatives for the first time since
COVID-19. Improved analysis of safety data was available to prison management
and to the IMB. Another positive development was a fortnightly Safety Intervention
Meeting.
Previous deaths at HMP Pentonville
29. Mr Campbell was the sixth prisoner to die at Pentonville since October 2021. Of the
previous deaths, two were self-inflicted and three were from natural causes. Up to
the end of April 2025, there had been four deaths at Pentonville since Mr
Campbell’s death. Three were self-inflicted and one was natural causes.
Assessment, Care in Custody and Teamwork
30. Assessment Care in Custody and Teamwork (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.
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31. 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. As part of the
process, a caremap identifying support actions is put in place. The ACCT plan
should not be closed until all the support actions on the caremap have been
completed.
Psychoactive Substances (PS)
32. The term psychoactive substances is a broad term that refers to a drug or other
substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazene) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
33. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
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Key Events
34. On 9 March 2024, Mr Peter Campbell was remanded to HMP Wormwood Scrubs
charged with burglary. On 9 April, he transferred to HMP Pentonville.
35. Mr Campbell had a history of schizophrenia and depression. He had previously
been sectioned under the Mental Health Act several times and received treatment
in a psychiatric hospital. He received medication for his conditions.
36. Nurse A carried out a reception health screen. Mr Campbell said he had
schizophrenia and depression for which he received medication, but he could not
remember what. He said he used cannabis but not alcohol. The nurse referred Mr
Campbell to the mental health team for review and to clarify his medication needs.
37. On 10 April, Ms A carried out a medication reconciliation and noted Mr Campbell
had previously been prescribed Flupentixol (an antipsychotic – 400mg every four
weeks) administered by injection by his Community Mental Health Team. Ms A let
the mental health team know.
38. That day, Nurse B carried out a mental health assessment. She noted Mr Campbell
had a number of risk factors including that he ate his own faeces in response to
auditory command hallucinations and he was potentially vulnerable to bullying.
(These concerns were discussed with one of the prison doctors and it was agreed a
number of welfare checks should be undertaken over the coming weekend to
ensure his safety.) Nurse B noted that Mr Campbell could also be at high risk of
deteriorating mental/physical health due to ongoing drug use, but he had declined
support from Phoenix Futures, the psychosocial substance misuse service.
39. On 16 April, the mental health team reviewed Mr Campbell’s case and he was
added to their case load. A member of the Phoenix Futures team, Ms B, noted that
Mr Campbell had completed their induction but said he did not want to work with
their service. He said he did not have a problem with substances, but she gave him
harm minimisation advice and was content he knew how to contact them if he
changed his mind.
40. On 17 April, Nurse B reviewed Mr Campbell’s care plan. Mr Campbell asked her
when he would be admitted to a psychiatric hospital and said he did not think he
could cope in prison. She told him more information was needed and a psychiatrist
would need to assess him. She noted he and his cell were clean and that she had
offered him distraction materials which he had declined. He did not want her to refer
him to the Wellbeing Centre or for education but he said he would let her know
when he was ready.
ACCT 18 April to 5 June 2024
41. On 18 April, Mr Campbell told Officer A he had been eating his own faeces as he
wanted to harm himself and end his life. Officer A started ACCT procedures and
took Mr Campbell to see Nurse C. The ACCT concern form was left blank.
42. Supervising Officer (SO) A completed the Immediate Action Plan and set the
frequency of checks at one an hour, with a requirement for staff to record three daily
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conversations with Mr Campbell. SO A’s record does not say whether staff had
established why Mr Campbell was self-harming, but she noted he said he
recreationally used drugs and wanted to call his family and that their phone
numbers had been cleared. SO A did not comment on whether Mr Campbell had
any phone credit at that point, but Mr Campbell went on to make calls while he was
at Pentonville.
43. On 19 April, SO B carried out the ACCT assessment at the same time SO A chaired
Mr Campbell’s ACCT review. Mr A (from the healthcare team) attended. Mr
Campbell said he ate faeces as a way to self-harm and had last done this two days
previously. He said he had been sectioned several times, tried to jump off a cliff
once and had been on lots of medication (including by depot injection) in the
community. He said he had been hearing voices since his mother died 20 years
earlier.
44. Mr A said he would talk to a colleague about Mr Campbell’s medication and that the
healthcare team were looking into transferring him to a secure hospital. Mr
Campbell said his father was no longer picking up his calls and his stepmother did
not want to speak to him but one of his brothers wanted to visit him. He was told
how to arrange visits. Mr Campbell also talked about a complex relationship with his
wife and children.
45. Mr Campbell said he had used crack and cocaine prior to being remanded to
prison, but he was still not interested in working with Phoenix Futures. The review
also covered his court case and one of the attendees said he would get him a
number for his solicitor. Attendees checked he knew how to contact Listeners
(prisoners trained by the Samaritans to provide a listening service) and Samaritans.
46. Care plan actions included that Mr Campbell was to book visits for his brother and
the mental health team should see Mr Campbell – the latter action was assigned to
Mr A. Another action was for Mr Campbell to move off the wing so he could attend
the gym and SO A was assigned to this. SO B had an action to contact an
organisation who could help Mr Campbell contact his children. ACCT review
attendees agreed Mr Campbell’s ACCT would remain open on two hourly
observations with three daily conversations until his next review on 29 April.
47. On 23 April, staff found Mr Campbell unresponsive in his cell possibly as a result of
PS. A nurse reviewed him and noted no further clinical concerns.
48. On 29 April, SO C held an ACCT review. Mr Campbell said he was in crisis and had
consumed his faeces that day. He believed he should be in hospital and
complained about not having a TV and kettle in his cell, then later said he had sold
them. He also said he had recently used drugs on the wing. SO C contacted the
mental health in-reach team who said that they would carry out a mood review on
the 2 May. Mr Campbell was not interested in any purposeful activity or any input
from the substance misuse service. An action was added to the care plan for him to
complete a Basic Skills Assessment (BSA) so he could do activities. Mr Campbell
said that he would continue to eat his own waste. SO C noted the ACCT was to
remain open with one observation every three hours, and one morning and one
afternoon conversation.
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49. On 2 May, Mr Campbell told wing staff he had swallowed a vape battery.
Healthcare staff took observations and monitored him for two days.
50. On 16 May, SO D was due to hold an ACCT review with Mr Campbell and
healthcare staff but she suspected Mr Campbell was under the influence of PS and
rescheduled it to the following day. She increased ACCT observations to twice an
hour. Staff seized drug paraphernalia from Mr Campbell’s cell and submitted an
intelligence report. Security staff concluded that no further action was needed at
that time.
51. The next day, Mr Campbell was found under the influence of drugs again and staff
submitted another intelligence report. Healthcare staff attended and deemed no
treatment was necessary. The security team completed an intelligence assessment
and concluded that it was a likely a named prisoner was supplying drugs to other
prisoners including Mr Campbell.
52. On 18 May, SO E held an ACCT review. Officer B from the wing also attended. Mr
Campbell said he had no thoughts of suicide or self-harm but said that he had
swallowed a vape and no one was taking him seriously. Mr Campbell said that he
had been sectioned before and wanted to go to a psychiatric facility. SO E
maintained half-hourly observations.
53. On 19 May, a member of staff submitted an intelligence report stating Mr Campbell
had been seen visiting a known PS user’s cell. The security assessment concluded
this was ‘building block’ intelligence, meaning it was something that might contribute
to a bigger picture.
54. On 20 May, SO F held an ACCT review and SO D attended. Mr Campbell seemed
much better and was fully coherent. He said he liked to smoke PS when things got
on top of him so he could feel ‘nothing’. SO F discussed the dangers of PS and
ways he could better himself. Mr Campbell said he was interested in education and
SO F noted he was going to take that forward for Mr Campbell. Mr Campbell
expressed a wish to repair his relationship with his children and said that he would
give anything a try to help with that. SO F reduced observations to hourly (although
his note said he was maintaining them at two an hour) with a morning and afternoon
conversation.
55. On 20 May, Mr Campbell spoke to Mr B from Phoenix Futures. He said he needed
help addressing his substance use. Mr B gave harm reduction advice and noted Mr
Campbell needed an assessment.
56. On 22 May, a member of staff submitted an intelligence report following information
from a prisoner to say that approximately three weeks previously, Mr Campbell had
held another prisoner at knifepoint and an improvised knife had been found in his
cell. The intelligence assessment referenced ‘mash’ (we do not know what this term
referred to in this context but it can mean drugs or weapons) and a zanco (a small
phone) and implied that the argument had probably been about the phone. The
suspected supplier’s cell cited on 19 May was searched on 22 May in relation to
that incident, and Mr Campbell’s was searched on 22 May also – presumably as a
result of cumulative incidents. Staff did not recover anything of note from either cell.
A member of the Security team told us that the individuals were personally
searched too, but nothing was found.
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57. On 23 May, Mr C from Phoenix Futures, tried to carry out a substance misuse
assessment but Mr Campbell would not engage.
58. On 27 May, SO F held an ACCT review. Mr Campbell said he had been feeling
quite well and had been taking much less PS than he usually did. He seemed
happy about it and said he could think more clearly. SO F asked Mr Campbell if he
still wanted to enrol on an English education programme, and he said he was very
keen and thought it would really benefit him. SO F said he had already spoken to
the education department, but they were yet to action it. Mr Campbell said he would
not completely stop using PS at that time but was determined to keep lowering the
amounts. SO F explained that he understood and that using the drug less was a
step closer to becoming clean. SO F decided to keep Mr Campbell’s ACCT open
but reduced observations to once every three hours with one morning and one
afternoon conversation.
59. On 4 June, Mr Campbell completed a psychosocial substance misuse session with
Mr C and was given some workbooks to complete.
60. On 5 June, SO F held an ACCT review and another officer attended. Mr Campbell
said he had halved his PS use and had no thoughts of suicide or self-harm. SO F
reminded him he could speak to healthcare staff if he needed any help related to
substance misuse. He said he was looking forward to starting his education course.
SO F closed the ACCT.
61. On 13 June, SO F held a post-closure review and the ACCT remained closed as
there were no concerns. In the post-closure form section where the SO and
prisoner should review the actions detailed in the support plan, SO F noted that Mr
Campbell no longer ate his own waste as a method of self-harm and he had chosen
not to have a TV in his cell as it was more peaceful without it. He did not make any
reference to the other matters raised in the ACCT support plan.
62. On 19 July, a member of staff submitted an intelligence report saying that Mr
Campbell was suspected, along with other prisoners, of moving drugs around the
prison. The intelligence assessment concluded that it was likely the prisoners were
using PS but not what action would be taken.
63. On 6 August, staff submitted an intelligence report to say Mr Campbell had been
found under the influence of drugs in another prisoner’s cell. The assessment said
the information would be copied to another named prison (presumably because the
other prisoner had moved there).
64. On 14 August, Mr Campbell was involved in a fight although the reasons for this
were not clear as he would not give staff any details. Staff submitted an intelligence
report and the analyst concluded it was building block intelligence and no
assessment was necessary at that time.
65. On 26 August, Mr Campbell told Officer C he had been assaulted. He would not talk
about it or give any names but he provided the prisoners’ cell numbers. A member
of staff submitted an intelligence report and the analyst concluded it was building
block intelligence and an assessment was not required at that time.
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66. On 17 and 18 September, staff noted that Mr Campbell seemed under the influence
of drugs. They called the healthcare unit and submitted an intelligence report.
67. Also on 18 September, Officer D referred Mr Campbell to the safeguarding team
because Mr Campbell’s personal hygiene was poor, he did not socialise much, and
he seemed to be struggling with a PS addiction. Officer D felt Mr Campbell would
benefit from some extra support.
68. On 19 September, Mr Campbell had an in-person review with Consultant
Psychiatrist Dr A. She concluded that although he had schizophrenia, he was not
acutely unwell, so a hospital transfer was not appropriate.
69. That day, Nurse D also completed a safeguarding referral for Mr Campbell. This
outlined a concern that he was being used as a ‘guinea pig’ to test the potency of
batches of PS arriving in the prison and that he was vulnerable because he had
mental health issues.
70. On 23 September, the safety team held a Safety Intervention Meeting where
safeguarding referrals were discussed. No meeting minutes were taken, but Mr
Campbell should have been discussed and an action set for a member of the safety
team to interview him. There is no evidence this happened. As no one raised an
action (if he was discussed), he was not discussed at following weeks’ meetings.
71. On 30 September, Mr C saw Mr Campbell for a psychosocial session but Mr
Campbell said he was busy cleaning a cell. On 1 October, Ms C saw Mr Campbell
for some harm reduction work. He seemed drowsy but denied he had taken
substances. He denied any thoughts of suicide or self-harm and Ms C gave him
information about the dangers of PS use.
72. That day, Mr Campbell had his last review with his mental health in reach team
keyworker Nurse B before his death. (He had over 20 sessions in total). She was
checking in on him because the day before he had told her he was due in court on 1
October and was optimistic about being released soon. (His court date was not, in
fact, until 7 October.) Nurse B had no concerns.
Events of 3 October
73. The following account has been taken from CCTV footage and staff and prisoner
statements.
74. On 3 October, Officer E noted in Mr Campbell’s record that he had failed a
mandatory drug test for PS and been put on report. (The test had been taken on 26
September.) Officer E did not see Mr Campbell face to face.
75. At 3.30pm, Mr Campbell refused to collect his medication and told Officer F that he
wanted to stay in his cell. She informed the pharmacist.
76. At 3.48pm, a prisoner put something under Mr Campbell and his cellmate’s door
and another prisoner briefly visited them shortly after.
77. At approximately 4:55pm, Officer G went to speak to Mr Campbell about a property
matter. She could see Mr Campbell’s legs positioned as if he were sat on the bunk
and his cellmate was stood up in the cell. She felt something was wrong and went
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into the cell calling for another officer behind her to come with her. When she
opened the door, Mr Campbell’s cellmate left immediately.
78. Mr Campbell was sitting on the bottom bunk, leaning to his right side with saliva
dripping out of his mouth. Officer G could smell PS and radioed a code blue
(indicating a prisoner is unconscious or is having breathing difficulties) at 4.55pm.
Staff in the control room called an ambulance. Officer G put Mr Campbell in the
recovery position and Custodial Manager (CM) A, CM B and SO D attended. When
they realised that Mr Campbell was unconscious and not breathing, the officers
commenced cardiopulmonary resuscitation.
79. At 4.58pm, Nurse F and Nurse G attended and applied a defibrillator and delivered
oxygen to Mr Campbell.
80. At 5:07pm, paramedics arrived and took over resuscitation efforts. They restored Mr
Campbell's pulse using the automatic defibrillator and stabilised him for transport to
hospital at approximately 6.00pm. Mr Campbell remained unconscious.
81. Staff did not apply any restraints while Mr Campbell was transferred or during his
stay in hospital.
82. Mr Campbell did not recover and on 8 October, at 5.35pm, he died.
Contact with Mr Campbell’s family
83. On 3 October, the prison appointed CM C as the family liaison officer. He attempted
to contact Mr Campbell’s father several times to let him know his son was in
hospital but did not manage to speak to him until 7 October.
84. Mr Campbell’s father said he did not want contact from the prison, but after his
death the prison wrote to him and offered a contribution to funeral expenses in line
with national policy.
Support for prisoners and staff
85. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support).
86. In line with this approach the Samaritans attended Pentonville and supported
Listeners completing their duties.
87. After Mr Campbell’s death, the duty 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.
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88. The prison posted notices informing other prisoners of Mr Campbell’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Campbell’s death.
Post-mortem report
89. The post-mortem report gave Mr Campbell’s cause of death as pneumonia and
ischaemic hypoxic brain injury caused by a cardiac arrest following alleged use of
synthetic cannabis. No toxicology tests were carried out.
Inquest
90. The Coroner’s inquest, held on 10 March 2026, determined the medical cause of
death to be drug related.
91. The jury’s narrative verdict concluded that there was a failure to prevent drugs from
entering the prison, there was a failure from drug and alcohol services to provide a
meaningful interaction with Mr Campbell following a serious drug related incident on
18 September 2024, for which he required resuscitation, there were reports that Mr
Campbell was likely testing new batches of spice within the prison, and a failure to
act on this intelligence. The impact of these failures on Mr Campbell’s death was
considered unclear.
92. On 11 March 206, the Coroner issued a Prevention of Future Deaths notice.
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Findings
Assessment of Mr Campbell’s risk of suicide and self-harm
93. We have no reason to believe Mr Campbell’s fatal PS use was a result of attempted
suicide or self-harm. However, effective ACCT management can highlight issues
which may cause an individual to use substances and seek to address those as
part of a meaningful support plan.
94. Mr Campbell was subject to ACCT procedures while at Pentonville. His ACCT case
reviews were held when they should have been, attendance was sometimes multi-
disciplinary and detailed accounts of the reviews were written up. However, the
investigator found that at the post-closure review on 13 June, the discussion about
the support plan and what had changed since the ACCT had opened did not seem
to cover the matters in the support plan. SO F was content to close the ACCT
because Mr Campbell was no longer eating his own waste as a means to self-harm
and he had decided to not have a TV in his room. Although the records suggest Mr
Campbell did engage to some degree with education and considered seeing family,
SO F did not reference how these actions had progressed specifically and it is
unclear what happened with regards to him contacting his children. We make the
following recommendation:
The Governor should ensure that ACCT care plan actions are regularly quality
assured to satisfy himself that all actions have been fully completed.
Drug strategy at Pentonville
95. Mr Campbell was regularly found under the influence of substances at Pentonville
and was apparently able to obtain them with ease. We have considered the
effectiveness of the prison’s approach to reducing the availability of drugs.
96. The investigator interviewed Mr D, the head of Pentonville’s drug strategy. He took
up post in May 2024 and said he was advised to wait for the national drug strategy
to be published before tailoring it for a local approach and producing a drug strategy
document for Pentonville.
97. Mr D said that he focused on liaising with the regional drug strategy lead and set up
monthly drug strategy meetings at Pentonville which other heads of function,
healthcare staff and Phoenix Futures attend. More recently, Mr D has invited
prisoners too. In common with other strategic approaches, Mr D’s emphasis has
been on restricting supply, reducing demand, and also building recovery.
98. The monthly drug strategy meeting discusses data collected on drug finds (and
specifically PS), locations of finds, scan results, under the influence numbers,
healthcare data on emergency codes, drug testing results, voluntary drug testing,
Phoenix Futures information and pharmacy statistics on abused medications. Data
collected for a drug strategy meeting showed 48 code blues called in September
2024 for prisoners under the influence and 23 of these were suspected to relate to
PS.
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99. Mr D said that the forensic service they used to provide drug test results could not
keep up with demand and the turnaround time for test results could be as much as
70-80 days which impacted on the prison’s ability to take an intelligence led
approach to substance misuse. The investigator asked Mr D for an update on this
situation. He said that shortly after the PPO interview, the national key forensic
testing was paused and an interim urgent request system put in place instead,
approved by the regional drug strategy lead. Key forensic testing has now restarted
with the head of security taking the lead on requests. However, it is not clear to us if
this has improved timeliness.
100. If a rapid response to an issue is required (for example a sharp increase in code
blues related to a batch of PS) the matter is discussed at the morning meeting or
sometimes over email and a response formulated. Mr D said Practice Plus Group
have been good at relaying nurses’ concerns and thoughts about drug use and that,
recently, the prison decided to hold a ‘wing surgery’ in response to PPG led
information. Phoenix Futures and healthcare staff took part and gave prisoners
harm minimisation advice and education regarding the dangers of PS. Drug
amnesties have also been held. After Mr Campbell’s death, an amnesty was run on
his wing specifically in response to his death.
101. Drug testing is carried out at Pentonville including random tests, suspicion-based
testing (as a result of intelligence tests) and area based (risk-based) testing
(because certain parts of the prison may be more susceptible to drug activity).
Frequent testing, which had been used in the past for serial abusers, had been
stopped but there are plans to reintroduce it as an alternative to disciplinary action.
Voluntary testing takes place twice a month on the Incentivised Substance Free
Living wing.
102. Searches can be carried out in response to intelligence and will be assigned a
priority which indicates how quickly the search should be done. Enhanced gate
security and other measures had led to higher numbers of staff being searched and
suspensions and this seemed to have had a knock-on effect in the form of more
throwovers (items being thrown over the perimeter wall rather than brought in
through staff or visits).
103. Pentonville also agreed to be part of two research projects about substance misuse
– one run by the NHS and another by a social enterprise, which they hope will give
them some prisoner insights and help formulate their drug strategy.
Security and intelligence reports
104. Staff submitted a number of intelligence reports suggesting that Mr Campbell was
using drugs. Analysts often considered these to be ‘building block’ intelligence or, in
other words, part of something that may or may not contribute to a bigger picture,
but it was considered too early to tell.
105. The investigator spoke to Mr E, Pentonville’s Head of Security. She reflected that it
was good to see that staff submitted intelligence reports even when all they had
were suspicions of drug use. What was not clear to her, however, was when a
collection of reports should have triggered some action. Mr E said that he would
have expected three reports, from different sources, and in a reasonably short time
frame, to trigger a suspicion drug test and a cell search.
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106. Staff submitted intelligence reports on 16, 17 and 19 May all relating to Mr
Campbell’s suspected PS use or his visiting a known user’s cell. There is no
evidence that Mr Campbell was asked to take a drugs test. On 22 May another
intelligence report was submitted regarding Mr Campbell’s involvement in weapons
and phones. A prisoner had offered the information, referring to an incident he
claimed to have witnessed approximately three weeks before. The same day that
information was received, a suspected supplier’s cell, who Mr Campbell had been
seen visiting, was searched and nothing found. Mr Campbell’s cell was also
searched, and nothing was recovered from his either.
107. After this, staff submitted four intelligence reports relating to Mr Campbell’s possible
involvement in moving drugs around, fights and being under the influence of drugs.
There is no evidence that apart from intelligence being shared with managers any
other action was taken.
108. On 26 September, Mr Campbell was subject to a random (not suspicion-led) drug
test. The results were positive.
109. While it is possible that some actions were taken and not recorded in the main
record, or that actions were taken against other prisoners involved in some of these
instances it seems that there was much information coming in about Mr Campbell
that might have prompted security staff to act again when more instances occurred
after his cell had been searched. However, we note the excellent and frequent
support Mr Campbell was getting from his mental health in reach key worker and
wonder what testing or cell searches might have achieved in terms of keeping Mr
Campbell safe. We do not make a recommendation but the Governor and Head of
Security might wish to consider the intelligence reports relating to Mr Campbell and
analysts’ subsequent decisions and consider any learning.
Safeguarding Referrals
110. On 18 and 19 September, two separate members of staff made safeguarding
referrals for Mr Campbell. Concerns had escalated about Mr Campbell over and
above his drug use. His personal hygiene was poor, and staff thought he was
possibly being bullied. The safeguarding referrals should have prompted a member
of the safety team to interview Mr Campbell, discuss how he could be helped and
potentially put in place support measures if they also thought he was a victim of
bullying. However, neither referral was acted on because staff were either on leave
or rest days.
111. The prison could not tell us why no minutes of the safeguarding meeting on 23
September were taken and we were not able to determine whether Mr Campbell
was discussed at all, or any actions agreed. This was a missed opportunity to
intervene at a point so close to Mr Campbell’s death and the failure to respond to
the referrals appears to have been the result of administrative failures. We make
the following recommendation:
The Head of Safety should ensure members of the team keep SIM meeting
minutes and that, as far as is reasonably possible, there is adequate cover
when staff are on leave to deal with safeguarding referrals.
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Substance misuse care
112. Mr Campbell had an established history of substance misuse, and in the community
his preferred drugs were cannabis and cocaine. However, in prison he tended to
use PS (presumably because it was easy to obtain).
113. Mr Campbell was offered support from Phoenix Futures, the prison’s psychosocial
substance misuse service. He often did not want to engage or only did so for a
short while.
114. The clinical reviewer found a lack of detail in the records regarding Mr Campbell’s
drug use and little evidence that staff discussed or considered his motivations for
using substances or reasons why he may not wish or be able to stop. Although
recognising that this may have been because he did not wish to engage, she found
advice offered to him centred on harm minimisation and risk education. While she
recognised the merit in this in helping to keep individuals who are going to use
drugs safe, she did not feel it did much to address behaviour changes.
115. That being said, the clinical reviewer was pleased to see that after the incident
which saw Mr Campbell admitted to hospital before his death, drug and alcohol
services delivered widespread outreach and harm reduction advice to the prisoners.
116. Phoenix Futures were unable to see Mr Campbell every six weeks as expected
because of capacity issues, but it seemed the healthcare and custodial
management teams were unaware of this issue. Also, attempts where staff did try to
see Mr Campbell but could not because he was under the influence of drugs were
not always documented and there were periods where the Phoenix Futures task
inbox was not monitored for a prolonged period. We bring these issues to the
Phoenix Futures manager’s attention.
Mental Health care
117. The clinical reviewer concluded that the healthcare Mr Campbell received at
Pentonville was equivalent to what he could have expected to receive in the
community.
118. Nurse H’s input was particularly impressive, and she paid attention to risk triggers
and made efforts to communicate with Mr Campbell’s community mental health
team. However, there were other areas of Mr Campbell’s mental health care which
were not so good. Mr Campbell had a diagnosis of schizophrenia which manifested
as voices and paranoid thoughts. Sometimes he believed the voices commanded
him to eat his own waste or they would harm his children. Mr Campbell had also
suffered from periods of depression in the past. He was receiving medication via an
injection for his schizophrenia, but although he told the reception nurse he suffered
from depression too there is no evidence that any action was taken to assess his
mood.
119. A psychiatrist never formally reviewed Mr Campbell’s medication while he was in
prison even though he told staff he had sometimes took medication orally too which
made him feel better. This was probably Haloperidol which, in the past, he had
been prescribed in addition to his injection. While the clinical reviewer noted that it
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is not best practice to top up injectable antipsychotic medication with oral, she felt
there was scope to increase Mr Campbell’s depot medication.
120. Mr Campbell had had a number of admissions to psychiatric hospitals in the past
and his desire to return to one is evident in the clinical records. Staff told him he
needed to be assessed, but this did not happen for five months, and a decision was
made that he did not meet the criteria. The clinical reviewer considered that while
this was the right decision because he was not acutely unwell, this was evident from
the start. A consultant psychiatrist had assessed Mr Campbell at Wormwood
Scrubs, five days before he transferred to Pentonville, and arrived at much the
same conclusion. The clinical reviewer considered that the mental health team
could have reassured Mr Campbell that they could cater for his needs, as had
happened in the community, and not raised his hopes of a hospital transfer.
121. The clinical reviewer has made recommendations about Mr Cambell’s substance
misuse and mental health care, not directly related to his death, which the Head of
Healthcare will wish to address.
Good Practice
122. We are pleased to note that Mr Campbell’s medical condition was fully considered
and staff did not apply restraints when he was taken to hospital.
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