Before Assistant Coroner Jonathan Stevens
Bow Coroner’s Court, Bow Road, London, E3 3AA
19 – 30 January 2026
Gareth Chumber-Kelly, 33, died a self-inflicted death only four days after being remanded to HMP Pentonville. Now an inquest has found that multiple failures including a failure to refer him for appropriate mental health care contributed to his death.
Since Gareth’s death, 12 people have died at Pentonville Prison. At least five of these deaths were self-inflicted.
Gareth was a hard-working and loving father of three from Enfield, London. Resourceful and clever from a young age, he saved up enough money aged 15 to take his mother and sister on holiday. His family remember him for his love of cars, technology, music and Indian food.
Gareth had a long history of self-harm and suicide attempts. Gareth began using drugs to cope with the consequences of a life-changing brain injury as a teenager.
On 13 July 2023, Gareth was remanded to HMP Pentonville. He arrived at the prison with a Suicide/Self-Harm warning form stating that Gareth said he would take his own life if he was sent to prison. It also noted his history of suicide and self-harm.
This information was not acted on by the prison, prison healthcare provider or mental health team, despite all three organisations being provided with the information. Evidence heard at the inquest also found that important paperwork from Gareth’s first night in the prison was lost by the prison.
The next day, Gareth was moved to the detox wing where he self-harmed. The healthcare staff attending did not make a referral to the mental health team, contrary to internal policies.
Following this incident, a prison officer put in place a safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) and placed Gareth under hourly observations with two meaningful conversations with prison officers per day. Evidence at the inquest found key sections of this document were not completed adequately or at all; no care plan for Gareth was put in place identifying risks, triggers and protective factors; no referral was made to mental health support; and Gareth was left in his cell with items that posed a risk to him.
Evidence heard at the inquest found that ACCT conversations were skipped and the majority which were completed were brief entries which did not demonstrate that any meaningful interaction had taken place. The hourly observations were not always carried out and on the morning of 17 July 2023 some entries were falsified. One prison officer admitted to falsifying the entry of the last time that Gareth was seen alive by prison staff. This is understood to have happened while the emergency response was ongoing.
In the morning of 17 July, Gareth’s cellmate found Gareth having tied a ligature in their shared cell and persuaded him to come down. In evidence given to the police, Gareth’s cellmate suggested that the ligature was left tied to the window throughout the morning.
At 12.35pm, Gareth’s cellmate found him again having ligatured from the same window and pressed the emergency cell bell. Giving evidence at the inquest, the two officers who arrived at the scene did not make any attempt to resuscitate Gareth. They said that they ‘froze’ and ‘panicked’ and waited for healthcare to attend.
Resuscitation only began after healthcare staff arrived, who also admitted that they failed to bring a defibrillator with them to the scene. The healthcare staff also stood down the code blue on attending the cell after mistaking Gareth’s cell mate as the patient creating a delay in calling the ambulance.
Gareth was eventually taken to hospital by paramedics where he was pronounced deceased.
The jury concluded that Gareth died by ligature. They found that Gareth’s medical history and immediate circumstances posed a clear risk to life and that the following failures by the prison contributed to Gareth’s death:
- Inadequacies in the ACCT process
- The failure to provide Gareth with any mental health support available or a timely welfare call
- Insufficient checks for a ligature in Gareth’s cell
- Low levels of staffing and lack of staff training
Saroj Chumber, Gareth’s mother, said: “My son Gareth came round for dinner on Wednesday, was arrested on Thursday, taken to Pentonville prison on Friday and died on Monday. Gareth was handed a death sentence without even having been found guilty.
Me and my daughter Francessca, Gareth’s sister, have been broken by his death and nothing will ever be the same again.
Gareth was a very important and vital part of our three-unit family. We are completely broken without him; he was my only son and Francessca's only sibling. His presence, smile and chatter lit up the room and our lives. He was so full of life and always on the go. He can never be replaced.
The suffering my son went through in only four days at HMP Pentonville and the way he died is not something I will ever get over. I feel his human rights were breached every step of the way.
Since Gareth’s death, there have been several more self-inflicted deaths in HMP Pentonville. Every time I hear that someone else has suffered the way Gareth did, it’s a big kick in my face. These deaths must stop.
Pentonville prison must be closed down so that no one else has to go through what Gareth and our family went through.”
Read Saroj’s full statement here.
Kate Litman, Caseworker at INQUEST, said: “At the inquest, prison staff tried to paint a picture of Pentonville as a welcoming and supportive place of care and rehabilitation. This is grossly offensive to Gareth's family and insults the public's intelligence.
Prison was so unendurable that Gareth took his own life after just four days at Pentonville. Every agency that was supposed to protect Gareth failed to act on a clear warning that he was at risk. The person who did the most to protect Gareth was his cellmate.
Twelve people have died at the prison since Gareth, highlighting how recommendations from post-death investigations have failed to enact change.
To safeguard lives, we must dismantle prisons like Pentonville and invest in community alternatives that stop people coming into contact with prisons in the first place.”
Anna Thomson of Bhatt Murphy solicitors, said: “Gareth died only four days after being remanded to HMP Pentonville. Despite being informed that just hours before arriving Gareth had said he would kill himself in prison, staff failed to identify his risk or take necessary action to support him.
Although Gareth was ultimately placed on an ACCT after he self-harmed, the Inquest jury recognised that there were a number of serious inadequacies in the ACCT process, which meant that he wasn’t given the support that he needed.
Gareth’s death raises serious concerns about the safety of other vulnerable people in HMP Pentonville who, due to the nature of the regime, are completely reliant on the support of prison staff and organisations operating within the prison.
Our clients remain concerned that the measures taken by the prison since Gareth’s death do not adequately address the serious issues raised by Gareth’s death and that without proper change, cases like Gareth’s will continue to occur at HMP Pentonville.”
ENDS
NOTES TO EDITORS
For further information, a photo, and interview requests please contact leilahagmann@inquest.org.uk.
The family is represented by INQUEST Lawyers Group members Catriona McGregor, Anna Thomson and Catherine Shannon of Bhatt Murphy and Shanthi Sivakumaran of Doughty Street Chambers. They are supported by INQUEST Caseworker Kate Litman.
Other Interested persons represented are the Ministry of Justice, Practice Plus Group, North London NHS Foundation Trust, Together for Mental Wellbeing, Phoenix Futures, and North East London NHS Foundation Trust.
In Jully 2025, HM Inspectorate of Prisons (HMIP) issued an urgent notification for HMP Pentonville following an unannounced inspection that found: prisoners repeatedly illegally imprisoned beyond their release dates; wholly inadequate care for new prisoners; a high number of self-inflicted deaths; a failure to address deficiencies in internal processes; a widespread lack of support for prisoners at risk of self-harm; and squalid prison conditions.
In 2022, INQUEST published a report into the deaths of racialised people in prison between 2015-2022. The report uncovers new data and tells the stories of 22 racialised people and how they died preventable and premature deaths in prison. It evidences the role of institutional racism in the prison estate.
Gareth Chumber-Kelly
CONTENT WARNING: Please read with care as this page may involve information on death, suicide, mental illness, disability, state neglect, and police and prison violence that some people may find upsetting. If you need support, please visit our support page.
Before Assistant Coroner Jonathan Stevens
Bow Coroner’s Court, Bow Road, London, E3 3AA
19 – 30 January 2026
Gareth Chumber-Kelly, 33, died a self-inflicted death only four days after being remanded to HMP Pentonville. Now an inquest has found that multiple failures including a failure to refer him for appropriate mental health care contributed to his death.
Since Gareth’s death, 12 people have died at Pentonville Prison. At least five of these deaths were self-inflicted.
Gareth was a hard-working and loving father of three from Enfield, London. Resourceful and clever from a young age, he saved up enough money aged 15 to take his mother and sister on holiday. His family remember him for his love of cars, technology, music and Indian food.
Gareth had a long history of self-harm and suicide attempts. Gareth began using drugs to cope with the consequences of a life-changing brain injury as a teenager.
On 13 July 2023, Gareth was remanded to HMP Pentonville. He arrived at the prison with a Suicide/Self-Harm warning form stating that Gareth said he would take his own life if he was sent to prison. It also noted his history of suicide and self-harm.
This information was not acted on by the prison, prison healthcare provider or mental health team, despite all three organisations being provided with the information. Evidence heard at the inquest also found that important paperwork from Gareth’s first night in the prison was lost by the prison.
The next day, Gareth was moved to the detox wing where he self-harmed. The healthcare staff attending did not make a referral to the mental health team, contrary to internal policies.
Following this incident, a prison officer put in place a safety plan for prisoners at risk of suicide or self-harm (known as an ACCT) and placed Gareth under hourly observations with two meaningful conversations with prison officers per day. Evidence at the inquest found key sections of this document were not completed adequately or at all; no care plan for Gareth was put in place identifying risks, triggers and protective factors; no referral was made to mental health support; and Gareth was left in his cell with items that posed a risk to him.
Evidence heard at the inquest found that ACCT conversations were skipped and the majority which were completed were brief entries which did not demonstrate that any meaningful interaction had taken place. The hourly observations were not always carried out and on the morning of 17 July 2023 some entries were falsified. One prison officer admitted to falsifying the entry of the last time that Gareth was seen alive by prison staff. This is understood to have happened while the emergency response was ongoing.
In the morning of 17 July, Gareth’s cellmate found Gareth having tied a ligature in their shared cell and persuaded him to come down. In evidence given to the police, Gareth’s cellmate suggested that the ligature was left tied to the window throughout the morning.
At 12.35pm, Gareth’s cellmate found him again having ligatured from the same window and pressed the emergency cell bell. Giving evidence at the inquest, the two officers who arrived at the scene did not make any attempt to resuscitate Gareth. They said that they ‘froze’ and ‘panicked’ and waited for healthcare to attend.
Resuscitation only began after healthcare staff arrived, who also admitted that they failed to bring a defibrillator with them to the scene. The healthcare staff also stood down the code blue on attending the cell after mistaking Gareth’s cell mate as the patient creating a delay in calling the ambulance.
Gareth was eventually taken to hospital by paramedics where he was pronounced deceased.
The jury concluded that Gareth died by ligature. They found that Gareth’s medical history and immediate circumstances posed a clear risk to life and that the following failures by the prison contributed to Gareth’s death:
Saroj Chumber, Gareth’s mother, said: “My son Gareth came round for dinner on Wednesday, was arrested on Thursday, taken to Pentonville prison on Friday and died on Monday. Gareth was handed a death sentence without even having been found guilty.
Me and my daughter Francessca, Gareth’s sister, have been broken by his death and nothing will ever be the same again.
Gareth was a very important and vital part of our three-unit family. We are completely broken without him; he was my only son and Francessca's only sibling. His presence, smile and chatter lit up the room and our lives. He was so full of life and always on the go. He can never be replaced.
The suffering my son went through in only four days at HMP Pentonville and the way he died is not something I will ever get over. I feel his human rights were breached every step of the way.
Since Gareth’s death, there have been several more self-inflicted deaths in HMP Pentonville. Every time I hear that someone else has suffered the way Gareth did, it’s a big kick in my face. These deaths must stop.
Pentonville prison must be closed down so that no one else has to go through what Gareth and our family went through.”
Read Saroj’s full statement here.
Kate Litman, Caseworker at INQUEST, said: “At the inquest, prison staff tried to paint a picture of Pentonville as a welcoming and supportive place of care and rehabilitation. This is grossly offensive to Gareth's family and insults the public's intelligence.
Prison was so unendurable that Gareth took his own life after just four days at Pentonville. Every agency that was supposed to protect Gareth failed to act on a clear warning that he was at risk. The person who did the most to protect Gareth was his cellmate.
Twelve people have died at the prison since Gareth, highlighting how recommendations from post-death investigations have failed to enact change.
To safeguard lives, we must dismantle prisons like Pentonville and invest in community alternatives that stop people coming into contact with prisons in the first place.”
Anna Thomson of Bhatt Murphy solicitors, said: “Gareth died only four days after being remanded to HMP Pentonville. Despite being informed that just hours before arriving Gareth had said he would kill himself in prison, staff failed to identify his risk or take necessary action to support him.
Although Gareth was ultimately placed on an ACCT after he self-harmed, the Inquest jury recognised that there were a number of serious inadequacies in the ACCT process, which meant that he wasn’t given the support that he needed.
Gareth’s death raises serious concerns about the safety of other vulnerable people in HMP Pentonville who, due to the nature of the regime, are completely reliant on the support of prison staff and organisations operating within the prison.
Our clients remain concerned that the measures taken by the prison since Gareth’s death do not adequately address the serious issues raised by Gareth’s death and that without proper change, cases like Gareth’s will continue to occur at HMP Pentonville.”
ENDS
NOTES TO EDITORS
For further information, a photo, and interview requests please contact leilahagmann@inquest.org.uk.
The family is represented by INQUEST Lawyers Group members Catriona McGregor, Anna Thomson and Catherine Shannon of Bhatt Murphy and Shanthi Sivakumaran of Doughty Street Chambers. They are supported by INQUEST Caseworker Kate Litman.
Other Interested persons represented are the Ministry of Justice, Practice Plus Group, North London NHS Foundation Trust, Together for Mental Wellbeing, Phoenix Futures, and North East London NHS Foundation Trust.
In Jully 2025, HM Inspectorate of Prisons (HMIP) issued an urgent notification for HMP Pentonville following an unannounced inspection that found: prisoners repeatedly illegally imprisoned beyond their release dates; wholly inadequate care for new prisoners; a high number of self-inflicted deaths; a failure to address deficiencies in internal processes; a widespread lack of support for prisoners at risk of self-harm; and squalid prison conditions.
In 2022, INQUEST published a report into the deaths of racialised people in prison between 2015-2022. The report uncovers new data and tells the stories of 22 racialised people and how they died preventable and premature deaths in prison. It evidences the role of institutional racism in the prison estate.
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