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Pentonville prison’s failings exposed by Tyrone Givans cell death

Inquest into deaf prisoner who died ‘by hanging’ is told of faulty systems and drugs inside jail.

25 January, 2019 — By Emily Finch

Tyrone Givans’ mother Angela Augustin outside the inquest with barrister Adam Wagner and solicitor Chanel Dolcy 

AN inquest jury has condemned the care that an inmate at Pentonville prison received before he was found dead in his cell.

On Tuesday, a jury at St Pancras Coroner’s Court concluded that a profoundly deaf prisoner’s “needs [were] not being met” at the Victorian jail in Caledonian Road and “contributed to his death”.

Tyrone Givans 

Tyrone Givans, 32, died “by hanging” on February 26 last year but the jury added: “His intentions are unclear.”

The court heard that:

  • The IT system for prisoner records is “unfit for purpose” with a prisoner governor warning the faulty system can lead to prisoners being accidentally released early;
  • The prison officer in charge of looking after disabled prisoners was not aware of Mr Givans until after his death;
  • Mr Givans was not able to access a hearing aid until two weeks after he was in prison, leaving him “vulnerable”;
  • Drugs are readily available throughout the whole prison system, according to an officer and former inmate.

In its narrative conclusion, the jury said Mr Givans’ “issues” were “insufficiently processed and addressed by the prison and healthcare services.”

The jury said his “issues” included “chronic alcoholism” and “long-standing mental health problems including depression and anxiety” and that he was “profoundly deaf”.

They said the IT system for prisoner records was “unfit for purpose and that there is insufficient integration between different systems”. They found that the “recording of prison patient records was inadequate”.

Pentonville Prison

Mr Givans was found dead 19 days after entering prison. He had handed himself into Islington police after breaching a restraining order and had also been charged with assault.

The court heard that his hearing aids were at his ex-girlfriend’s house and Mr Givans’s mother had struggled to access them.

Giving evidence last Friday, Gary Poole, the prison governor for safer custody and equalities, slammed the prison’s record system used country-wide called Prison National Offender Management Information System (P-Nomis).

The governor, who is also a councillor for St Mary’s Ward, told the jury during cross-examination: “Currently, I don’t think it’s fit for purpose.”

He warned that the system could see prisoners released early or held for longer than their intended sentence.

Mr Poole explained that Mr Givans had four separate Nomis records with three separate dates of birth.

The court heard that Mr Givans had raised concerns over his records to prison staff less than two hours before his death.

The P-Nomis records “rests almost exclusively on court records”, according to Mr Poole and are created or edited by prison officers at the reception desk when booking in prisoners.

Mr Poole warned that they could take up to six months to correct and officers sometimes struggled to find the correct records if an inmate has a common name.

Every person who has been through the prison is listed in the system which was rolled out throughout the country in 2009 following a failed launch in 2004.

Mr Poole told the court “it’s a matter of regret that the equality officer wasn’t made aware” of Mr Givans’ presence.

The prison officer in charge of disabled prisoners and equalities was “cross employed on frontline delivery to prisoners” and “wasn’t able to dedicate all of his time to that role”. But Mr Poole added: “He is now not cross employed.”

Mr Givans’ mother, Angela Augustin, told the inquest: “Tyrone not having his hearing aids is like a visually impaired person not having a guide dog or someone who can’t walk not having a wheelchair. He really struggled.”

Ms Augustin managed to retrieve one hearing aid from her son’s estranged girlfriend after two weeks and gave it to her son but his deafness had left him “vulnerable”.

Ms Augustin, who works in Highbury, described her son as a “beautiful spirit and beautiful soul” who was “very close” to his eight-year-old daughter.

Speaking after the week-long inquest, mum Angela Augustin said: “We are pleased the jury have rightly acknowledged the failures of the prison and Care UK which contributed to Tyrone’s death. “Tyrone was profoundly deaf and very vulnerable. “He was scared without his hearing aids and we believe he suffered without support at HMP Pentonville. We hope to now move on and grieve the sad and avoidable loss of Tyrone.”

The coroner, Mary Hassell, said she would be writing a Prevention of Future Deaths report following the jury’s conclusions.

A spokeswoman for the Ministry of Justice failed to answer questions on the IT system used for keeping prisoner records.

The MOJ instead said: “This is a tragic case and our thoughts remain with the family and friends of Mr Givans. We will now carefully consider the inquest findings and take further action where necessary.”




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