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Medical staff have been criticised over the death of an inmate who hanged himself just over a month after being sent to Pentonville Prison, an inquest jury has found.

Samuel Rodney Darren Blair was found hanging by his shoelaces on August 2 last year after being remanded in custody for an alleged offence involving a knife.

The jury found that:

• Medical staff failed to properly assess Mr Blair’s 20-year mental health history.

• An emergency response nurse’s reaction was “inadequate”, taking up to 15 minutes to arrive after hearing about the incident.

• The fact all prison officers did not have lifesaving skills was a contributory factor in his death.

Head of safety at Pentonville, Gary Poole, also an Islington councillor, told the court it was lack of resources nationally that meant not all prison officers received lifesaving training.

Mr Blair, 40, originally from Northern Ireland, had a diagnosis of paranoid schizophrenia and had been on anti-depressants before entering prison but there was no plan to deal with either issue during his detention.

He went through an alcohol detox programme but was not prescribed anti-depressants despite the fact he would have carried on taking them if he were not in prison.

Aurora Diaz Lopez, head of healthcare at Pentonville, admitted that some elements of Mr Blair’s care were unsatisfactory.

St Pancras Coroner’s Court heard yesterday (Thursday) that his mental health had deteriorated significantly since the suicide of a friend, but he had never talked about ending his life. Numerous witnesses from Pentonville described Mr Blair as “low in mood” but not depressed.

Mr Blair, who was unmarried and lived in Enfield, had told his parents he was feeling “100 per cent better” after detoxing from alcohol and was even described as being in an “exceptionally good mood” on the day of his death.

But the inquest also heard claims from a serving prisoner that unemployed Mr Blair was “screaming and shouting in his cell”, claiming he was going to kill himself and had rung his cell bell several times.

Michael Prabucki told the court that a prison officer responded: “Do it quickly and don’t make a mess on my landing” just before 4pm.

Mr Prabucki said he was “sure what he heard” and claimed Mr Blair’s death “could have been easily prevented”.

But the officer denied the allegation, calling it a “total fabrication”. He added: “If Mr Blair said he was going to kill himself then straight away I would have got the nurse involved as a duty of care to him.”

A Prisons Ombudsman report found that Mr Blair’s cell bell had not been rung that day.

He was found in his cell just before 7.30pm and was pronounced dead by paramedics just under an hour later.

The jury found that another factor that contributed to Mr Blair’s death was that the prison officer who found Mr Blair did not have a radio.

Senior coroner for north London Mary Hassell said she would be issuing a prevention of future deaths notice listing eight concerns to Care UK, which provides healthcare at Pentonville.

She also raised issues with HM Pentonville and London Ambulance Service.

Ms Hassell said she would send a separate notice to the National Offender Management Service, which looks after prisons nationally, to raise concerns about the level of lifesaving skills among prison officers.