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Abstract

Senior coroner Mary Hassell has laid out her concerns about the “significant failures” of a private company which provides healthcare to in­mates at Pentonville Prison.

Her Prevention of Future Deaths report follows the inquest into the death of Terence Adams, 43, who killed himself at the Caledonian Road prison in November.

A jury at the inquest at St Pancras Coroner’s Court last month found that healthcare staff employed by Care UK at the prison did not take “immediate action” after Mr Adams’ admission, despite recording a “high risk of self harm”. He was found hanged by his bedsheets three days later.

In her report, the coroner was critical of the nurse and GP who first saw Mr Adams and carried out initial assessments.

He had received a score of eight on a mental health assessment, a result which should have triggered immediate admission to inpatient care at Pentonville, but this did not happen.

He should also have been put on an assessment, care in custody and teamwork (ACCT) document for prisoners at risk of suicide, but this was not done.

Ms Hassell’s report adds: “Mr Adams told the GP that he had been suicidal on and off for 20 years, but she did not explore with him the potential triggers for this. In fact, one such trigger was incarceration.”

She also expressed concern that staff did not seek to find out where Mr Adams was when he did not attend a second mental health screening on the morning he killed himself.

Finally, Ms Hassell said that a report carried out by Care UK after Mr Adams’ death in November last year was not shared with the coroner until part-way through the inquest, and even then only because it was accidentally discovered by two of the inquest advocates.

“These are significant failures, and it seems to me are an obstacle to learning lessons that may prevent future deaths,” Ms Hassell concluded.

The prison governor and Care UK now have 56 days to report back with a plan of action.

Ms Hassell issued a report critical of Care UK following the inquest into the death of Samuel Blair at Pentonville in May.

Care UK, the largest single provider of healthcare to HM Prison Service, won the contract to provide care at Pentonville in 2014.

Last week, the Tribune reported that the prison’s own independent monitoring board suggested in a report that Pentonville, which is over capacity by 400 inmates, should be knocked down and rebuilt unless urgent investment is forthcoming.

The report said staff shortages meant mental health assessments were sometimes taking place through locked cell doors. It highlighted the problem of formerly legal drug Spice being widely available at the prison, and said small drones were being used to sneak contraband through “shoddy” prison windows.

Five people have killed themselves inside its walls in the past 18 months.

A Prison Service spokesperson said: “The level of violence in our prisons is unacceptable. Safety in prisons is fundamental to the proper functioning of our justice system and a vital part of our reform plans.

“There are a number of factors including the availability of psychoactive substances in prisons which must be tackled. It will take time to address these long-standing problems, but we are determined to make sure our prisons are safe and places of rehabilitation.”