A North London prison has been called out by a coroner after a 20-year-old inmate facing deportation took his own life despite being on suicide watch.
By Josef Steen, Local Democracy Reporter
A North London prison has been called out by a coroner after a 20-year-old inmate facing deportation took his own life despite being on suicide watch.
Mujahid Adam, a prisoner at HMP Pentonville in Islington, may have survived if staff had checked in on him more often and kept proper records, an inquest found. After a previous attempt to take his own life in February 2025, Mr Adam was placed in a special cell reserved for inmates at risk of suicide.
Despite this putting him under “constant watch”, prison officers did not check in on him as often as they were supposed to. After his second attempt on March 15, 2025, it took staff over 30 minutes to discover him in his cell, but they delayed triggering the emergency signal. Mr Adam was taken to University College Hospital where he died six days later.
Coroner Edwin Buckett warned the Governor of Pentonville that systemic issues at the institution possibly contributed to his death.
Prison officers who were meant to be checking on vulnerable inmates every 15 minutes were not recording observations regularly because they weren’t allowed to take this form onto the wing. As a result, welfare reports were being written in one go at the end of their shift, making them highly prone to inaccuracy.
The inquest found the prison’s definition of what counted as a “satisfactory” observation was also unclear, and meant some officers were carrying out checks at a distance, including from behind a transparent door, instead of walking directly up to cells.
The jury also found the cell’s condition possibly provided a greater opportunity for Mr Adam to attempt suicide.
Second suicide flagged as concerning this year
The coroner’s report is the second issued to HMP Pentonville this year. In January, an investigation into the suicide of inmate Gareth Chumber-Kelly in July 2023 found similar institutional failings, including poor training for staff.
Mr Chumber-Kelly, 33, took his own life just four days after he was remanded to HMP Pentonville. The first two officers on the scene told the court they had “panicked and did not know what to do”.
He arrived at the prison with a suicide warning due to a long history of self-harm. A jury inquest heard that the prison, the healthcare provider, and the mental health team all failed to act on this information.
The coroner’s report highlighted several failings by the prison, including: not giving necessary CPR to save his life; inadequate reviewing of medical records; and insufficient checks on the risk in his cell.
The jury partly attributed these failings to low staffing levels and a prison lockdown during the critical hours.
In 2025, a damning report by the Chief Inspector of Prisons found over a third (38%) of prisoners felt suicidal on arrival at Pentonville. The inspector found there had been five self-inflicted deaths at the prison since July 2022, three of which took place in 2025.
HMP Pentonville has a duty to respond to the coroner’s reports into the deaths of Gareth Chumber-Kelly and Mujahid Adam by April 7 and May 1 respectively.
