Inquest jury finds that failure by HMP Pentonville to comply with previous PPO recommendation contributed to the death of Tedros Kahssay

The jury at the inquest into the death of Tedros Kahssay yesterday concluded that a number of errors by the police, prison and healthcare staff (Care UK) contributed to Tedros’ self-inflicted death at HMP Pentonville on 19 January 2016.

The jury concluded that:

  • The Person Escort Record (PER) that was supposed to record relevant risks of suicide did not flag the appropriate suicide risk;
  • The PER was not passed to healthcare staff by prison staff, contrary to the system in place at the time;
  • No holistic overview was taken of Tedros’ risk factors;
  • The risk assessment process was compromised;
  • The second health screen, administered the day after Tedros’ arrival into prison, did not probe Tedros’ history of depression because the PER was absent;
  • HMP Pentonville did not comply with the agreed recommendation of the Prisons and Probation Ombudsman arising from the self-inflicted death of Carl Foot in December 2014. The prison’s failure to implement the recommendation arising from Carl’s death impacted on the mental health assessment given to Tedros.

Tedros was an Eritrean national who had been granted asylum after fleeing his home country. The inquest heard that Tedros had been a victim of torture.

On 20 December 2015 Tedros was arrested on suspicion of murdering his pregnant partner. The police completed his PER form. Mandatory guidance states that an allegation of violence against a partner is a particular risk factor for self-harm and suicide and must be recorded on the PER. The police failed to record the nature of the allegation against Tedros and no member of prison or healthcare staff ever sought information on the allegation against Tedros. A number of witnesses told the inquest that they should have been aware of this information, that it would have informed their risk assessments, and that they would or might have acted differently had they known about it.

The PER form states that it must be passed to staff conducting the healthcare reception process. On arrival at HMP Pentonville on 21 December 2015, Tedros was assessed by a range of prison officers. None of them passed the PER to healthcare staff. All healthcare witnesses told the inquest that both at the time of Tedros’ death, and to this day, healthcare staff are not provided with the PER. The Deputy Head of Healthcare admitted that he was not aware that the PER document says it must go to healthcare. He also accepted that the failure to ensure that the PER and other relevant documentation reached healthcare put vulnerable prisoners at risk and that this risk was ongoing.

At the health screenings on his arrival, Tedros reported suffering from depression. Despite this background, and the nature of the allegation against him, no psychiatric referral was made. One of the nurses who assessed Tedros accepted that had he been provided with the relevant information about Tedros he would have referred him to a psychiatrist.
Tedros completed both the prison and healthcare induction processes on 22 December 2015. Between 22 December 2015 and 17 January 2016, only one meaningful face to face interaction with Tedros took place. Tedros’ NOMIS entry showed that he was never assigned a personal officer and a senior officer explained to the inquest that the prison did not run a personal officer scheme and still does not. This was despite HMP Pentonville informing the PPO in January 2014 that the prison was running a successful personal officer scheme.

On 17 January 2016, Tedros asked a senior officer to move him as he did not feel safe on the wing. Letters discovered after Tedros’ death indicated that he was being threatened. A move was arranged but Tedros declined to be moved, giving no explanation. The staff involved did not check Tedros’ risk factors or investigate further.

Later the same day, Tedros repeatedly banged on his cell door with a chair and said he needed to get out of his cell. The officer who spoke with him said that he was angry and agitated. He was moved to a cell on the same landing, on the same wing. The officer carrying out the move did not know Tedros, did not check his NOMIS entry or his risk factors, and put in place no plans to review Tedros’ situation.

On 19 January 2016 Tedros was found hanging in his cell. The efforts to revive him were chaotic, ineffective and characterised as sub-standard by the Deputy Head of Healthcare. The nurse carrying out CPR did not conduct any checks on Tedros before beginning chest compressions and the compressions were far too fast and too shallow.

The inquest heard evidence from the Governor for Safer Custody, Gary Poole, and the Deputy Head of Healthcare, Anthony Smith. It was accepted, following submissions from the family, that recommendations, and the steps taken to implement them following previous deaths at HMP Pentonville, could be relevant both to the causes of Tedros’ death and to the question whether the prison and Care UK had inadequate lesson-learning mechanisms which could require a Preventing Future Deaths (PFD) report from the Coroner.

Both the prison and the Head of Healthcare had accepted a PPO recommendation in January 2014 arising from the death of Satheeskumar Mahathevan requiring that reception healthcare staff take into account all relevant information. Both the Governor and the Head of Healthcare had informed the PPO in January 2014 that it was normal practice for the screening nurse to see a prisoner’s full core record. In November 2014, following a PFD report after the inquest into Mr Mahathevan’s death, the National Offender Management Service told the Coroner that healthcare staff at HMP Pentonville had access to all relevant documents, including the PER. The Governor and the Head of Healthcare reiterated that healthcare staff would be reminded of the need to assess all relevant information following the death of Carl Foot in December 2014. The prison stated that this action would be completed by December 2015.

The inquest heard evidence that these recommendations had not in fact been implemented, despite earlier assurances from the Governor and the Head of Healthcare. Neither the Governor nor the Deputy Head of Healthcare were able to explain why not. The Governor told the jury that healthcare staff do now receive all relevant information, including the PER. The Deputy Head of Healthcare made clear that this was still not happening. The Governor was unable to explain why he had a different understanding from the Deputy Head of Healthcare.

The Coroner indicated that she would be making a PFD report.

The family’s solicitor, Jo Eggleton says:

“This is yet another example of previous recommendations for improvement not being taken seriously and acted upon. It’s incomprehensible that something as fundamental as the PER is not seen by healthcare staff on reception. It’s a document used nationally to summarize relevant risk information for receiving organizations. The Governor and Care UK need to act immediately to ensure that it is always seen by reception healthcare staff”.

Tedros’s family are represented by Inquest Lawyers’ Group members Jo Eggleton, of Deighton Pierce Glynn, and Jesse Nicholls, of Doughty Street Chambers.