Mother calls for Pentonville closure after son's suicide in custody

A coroner’s jury found that Gareth Chumber-Kelly’s risk of suicide was not recognised during his four days at HMP Pentonville, where he was taken into custody on 13 July 2023 and died on 17 July 2023. The medical cause of death was suspension, and he was pronounced dead at University College Hospital.

Saroj Chumber, his mother, has now called for the north London prison to be closed. In her family statement, she said: “My son Gareth came round for dinner on Wednesday, was arrested on Thursday, taken to Pentonville prison on Friday and died on Monday.” She described him as her only son and the father of three children, and said prison staff did not allow him a phone call to contact his family on his first night.

The inquest, which concluded on 30 January 2026 after a 10-day jury hearing, found that Gareth’s medical history and immediate circumstances posed a clear risk to his life. That risk had been identified outside the prison, but was not engaged with or addressed once he arrived inside. The jury identified a string of failures: inadequate review of medical records, poor continuity of information during transfer of care, no mental health support or timely welfare call, insufficient ligature checks in his cell, low staffing levels, lockdown during crucial hours, lack of staff training and inadequate cover during break periods.

The coroner’s Prevention of Future Deaths report, dated 9 February 2026, was sent to HMP Pentonville, Serco, the Ministry of Justice and HM Prison and Probation Service. The report repeated the jury’s conclusion that the dangers were not properly recognised and that appropriate steps were not taken to prevent Gareth’s death.

At its 2025 inspection, HM Inspectorate of Prisons found the jail held 1,189 men and that 44% of prisoners felt unsafe. Inspectors found overcrowded cells, crumbling infrastructure and a fast-changing population that included men who were mentally ill, addicted to drugs, homeless or linked to gangs. They found some new arrivals locked in induction cells without bedding, pillows or cutlery, staff absent or asleep when meant to be supervising vulnerable men, and three self-inflicted deaths at the prison in 2025 alone. The prison was issued an Urgent Notification on 16 July 2025.

Opened in 1842 as a Victorian model prison, Pentonville has seen several more self-inflicted deaths since Gareth died, and an earlier HMIP review found there had been seven self-inflicted deaths since 2019. The Prison and Probation Ombudsman later listed his fatal incident report as published on 28 May 2026.