Inquest into hanged inmate death told how Pentonville Prison ‘failed to learn lesson of earlier death’
Jury finds jail risk assessment was compromised
12 December, 2016 — By Joe Cooper
ERRORS by police, prison and healthcare staff played a part in the death of inmate Tedros Kahssay, an inquest ruled on Monday.
Failure to comply with key recommendations following previous deaths at Pentonville Prison contributed to the death of the 28-year-old Eritrean refugee, who hanged himself in his cell in January, the jury said.
A key document – the person escort record (PER) – did not flag the appropriate suicide risk when filled in by police and was not passed by prison staff to healthcare staff – despite recommendations from the Prisons and Probation Ombudsman and assurances from prison bosses that changes had been made.
The jury said:
• No holistic overview was taken of Mr Kahssay’s risk factors.
• The risk assessment was compromised.
• 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 that death impacted on the mental health assessment given to Mr Kahssay.
The family’s solicitor, Jo Eggleton, told the Tribune: “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 summarise relevant risk information for receiving organisations.
“The governor and Care UK [the prison’s healthcare provider] need to act immediately to ensure it is always seen by reception healthcare staff.”
Mr Kahssay had been remanded in jail on a charge of murdering his pregnant partner. 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.
At the health screenings on his arrival, Mr Kahssay 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 Mr Kahssay accepted that, had he been provided with the relevant information about the prisoner, he would have referred him to a psychiatrist.
The inquest also heard conflicting evidence from governor for safer custody Gary Poole and deputy head of healthcare Anthony Smith about whether healthcare staff receive all relevant information. Mr Poole said they do but Mr Smith admitted he was not aware that the PER document says it must go to healthcare staff.
Inner North London coroner Mary Hassell indicated she would be making a substantial prevention of future deaths report.