Mujahid Adam
PFD Report
Partially Responded
Ref: 2026-0125
Coroner's Concerns (AI summary)
Inaccurate, non-contemporaneous recording of prisoner observations and an unclear definition of what constitutes an "observation" were identified. A disrepaired special cell, used for vulnerable prisoners, allowed access to ligature material which was missed during daily checks.
View full coroner's concerns
Evidence was given that:
1. If a prisoner was on 15-minute observations, a record of the observation checks on that prisoner would be made by a prisoner officer tasked with the responsibility for carrying out those checks.
2. That individual would write down those checks alongside their name, on a Form which was attached to the AACT Form in the office on the Wing. It was stated that it was not practicable to note observation checks as and when they occurred, because the officer concerned was not allowed to take the ACCT Form on the wing.
3. Furthermore, on rare occasions a record of such 15-minute checks might be made ‘in one go’ at the end of a shift. In other words, this could lead to more than 25 separate entries being written up in one go (assuming the same officer was expected to complete checks over 7 hours in a shift).
4. What amounted to a satisfactory observation of a prisoner is not defined by the prison. Evidence was given by a prisoner officer that he carried out checks at some distance away from the cell door. He stated that he did not always walk up to the door and look in, but relied upon the fact that he could see through the Perspex Outer cell door as the Inner Metal cell door was fully open.
5. The cell in which Mr Adam had been placed was in a state of disrepair. It was possible to access hidden scraps of bedding material for making a ligature, in a gap in the wall, where the u-bend of the toilet entered the wall.
6. Although the cell was subject to a daily “accommodation and fabric check” it was probable that this disrepair, in this location in this cell was missed by prison staff carrying out AFCs.
I am concerned that:
(a) The recording of observations of 15-minute checks is not contemporaneous and is prone to inaccuracy. It relies on a prison officer walking from the cell to the wing office to record observations, every 15 minutes, which may not be realistic if a prison officer has other duties to perform;
(b) There is no clear definition of what constitutes an “observation” and how this should be done by staff at the prison when someone is on 15-minute observations;
(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made. Despite daily AFCs, that disrepair was not noted although this was a special cell.
1. If a prisoner was on 15-minute observations, a record of the observation checks on that prisoner would be made by a prisoner officer tasked with the responsibility for carrying out those checks.
2. That individual would write down those checks alongside their name, on a Form which was attached to the AACT Form in the office on the Wing. It was stated that it was not practicable to note observation checks as and when they occurred, because the officer concerned was not allowed to take the ACCT Form on the wing.
3. Furthermore, on rare occasions a record of such 15-minute checks might be made ‘in one go’ at the end of a shift. In other words, this could lead to more than 25 separate entries being written up in one go (assuming the same officer was expected to complete checks over 7 hours in a shift).
4. What amounted to a satisfactory observation of a prisoner is not defined by the prison. Evidence was given by a prisoner officer that he carried out checks at some distance away from the cell door. He stated that he did not always walk up to the door and look in, but relied upon the fact that he could see through the Perspex Outer cell door as the Inner Metal cell door was fully open.
5. The cell in which Mr Adam had been placed was in a state of disrepair. It was possible to access hidden scraps of bedding material for making a ligature, in a gap in the wall, where the u-bend of the toilet entered the wall.
6. Although the cell was subject to a daily “accommodation and fabric check” it was probable that this disrepair, in this location in this cell was missed by prison staff carrying out AFCs.
I am concerned that:
(a) The recording of observations of 15-minute checks is not contemporaneous and is prone to inaccuracy. It relies on a prison officer walking from the cell to the wing office to record observations, every 15 minutes, which may not be realistic if a prison officer has other duties to perform;
(b) There is no clear definition of what constitutes an “observation” and how this should be done by staff at the prison when someone is on 15-minute observations;
(c) The cell occupied by Mr Adam is one of a handful of special cells in the prison which are used for vulnerable prisoners on constant watch or on 15-minute observation. It was in a state of disrepair and gave access to the hidden material from which a ligature could be made. Despite daily AFCs, that disrepair was not noted although this was a special cell.
Responses
Action Planned
• HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. • The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention measures to officers, including what constitutes an observation and how to perform one. • All newly recruited prison officers receive a full day of training on suicide and self-harm prevention as part of their initial prison officer training, which includes modules on the ACCT process. (AI summary)
• HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. • The local safety team will work in conjunction with the school to deliver training on self-harm and suicide prevention measures to officers, including what constitutes an observation and how to perform one. • All newly recruited prison officers receive a full day of training on suicide and self-harm prevention as part of their initial prison officer training, which includes modules on the ACCT process. (AI summary)
View full response
Dear Mr Buckett,
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR MUJAHID ADAM
Thank you for your Regulation 28 report of 3 March 2026 following the inquest into the death of Mujahid Adam at HMP Pentonville on 21 March 2025. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS).
I know that you will share a copy of this response with Mr Adam’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have raised concerns regarding the delivery of observations as part of the Assessment, Care in Custody, Teamwork (ACCT) document, the definition of an observation and the condition of constant supervision cells at HMP Pentonville.
All newly recruited prison officers receive a full day of training on suicide and self-harm prevention as part of their initial prison officer training, which includes modules on the ACCT process. During this training, staff are taught that observations are checks to ensure the welfare of the individual and that they must satisfy themselves that an individual is safe when conducting them. Officers are also advised that they must adhere to the frequency of observations set by the ACCT case review team for prisoners at risk of suicide and self-harm.
To ensure staff’s continuous understanding, HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. The local safety team will work in conjunction with the school
to deliver training on self-harm and suicide prevention measures to officers, including what constitutes an observation and how to perform one.
Prisoners may require more frequent observations depending on their level of risk, which can be labour intensive for staff. As you have noted, staff do not carry the ACCT document with them when conducting an observation. This is to mitigate the risk of other prisoners becoming privy to sensitive information about the individual being supported. It is also impractical for a member of staff to carry a large document whilst conducting their duties as it would restrict their ability to respond effectively to any emerging incidents. Due to this, the documenting of observations cannot be contemporaneous and must be completed after the event. Staff are required to complete these observations and record them either immediately or as soon as practicable afterwards, alongside their other duties. HMPPS recognises that there may be occasions when this is not feasible; in such circumstances, prisons may make local decisions regarding staffing on the wing to ensure staff feel able to record the required observations.
In response to concerns about the condition of constant supervision cells at HMP Pentonville, I can confirm that a bid has been submitted to upgrade these cells to ligature resistant specifications. This work will address any disrepair and reduce opportunities for prisoners to use the fabric of the accommodation to ligature. In addition, staff at HMP Pentonville have been reminded of their responsibility to complete daily accommodation fabric checks. These are physical checks of all prisoner living areas, including cells, to ensure that the area is clean, decent and fit for purpose. They are also valuable opportunities for staff to identify anything that raises suspicion, including items that can be used to ligature. The Duty Governor is required to ensure that the accommodation fabric check book has been signed before staff leave the establishment and to take appropriate action where necessary.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR MUJAHID ADAM
Thank you for your Regulation 28 report of 3 March 2026 following the inquest into the death of Mujahid Adam at HMP Pentonville on 21 March 2025. I am providing the response on behalf of His Majesty’s Prison and Probation Service (HMPPS).
I know that you will share a copy of this response with Mr Adam’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.
You have raised concerns regarding the delivery of observations as part of the Assessment, Care in Custody, Teamwork (ACCT) document, the definition of an observation and the condition of constant supervision cells at HMP Pentonville.
All newly recruited prison officers receive a full day of training on suicide and self-harm prevention as part of their initial prison officer training, which includes modules on the ACCT process. During this training, staff are taught that observations are checks to ensure the welfare of the individual and that they must satisfy themselves that an individual is safe when conducting them. Officers are also advised that they must adhere to the frequency of observations set by the ACCT case review team for prisoners at risk of suicide and self-harm.
To ensure staff’s continuous understanding, HMP Pentonville is re-introducing the “Pentonville Speed School”, which is an initiative that provides staff with bitesize training sessions in key subject areas. The local safety team will work in conjunction with the school
to deliver training on self-harm and suicide prevention measures to officers, including what constitutes an observation and how to perform one.
Prisoners may require more frequent observations depending on their level of risk, which can be labour intensive for staff. As you have noted, staff do not carry the ACCT document with them when conducting an observation. This is to mitigate the risk of other prisoners becoming privy to sensitive information about the individual being supported. It is also impractical for a member of staff to carry a large document whilst conducting their duties as it would restrict their ability to respond effectively to any emerging incidents. Due to this, the documenting of observations cannot be contemporaneous and must be completed after the event. Staff are required to complete these observations and record them either immediately or as soon as practicable afterwards, alongside their other duties. HMPPS recognises that there may be occasions when this is not feasible; in such circumstances, prisons may make local decisions regarding staffing on the wing to ensure staff feel able to record the required observations.
In response to concerns about the condition of constant supervision cells at HMP Pentonville, I can confirm that a bid has been submitted to upgrade these cells to ligature resistant specifications. This work will address any disrepair and reduce opportunities for prisoners to use the fabric of the accommodation to ligature. In addition, staff at HMP Pentonville have been reminded of their responsibility to complete daily accommodation fabric checks. These are physical checks of all prisoner living areas, including cells, to ensure that the area is clean, decent and fit for purpose. They are also valuable opportunities for staff to identify anything that raises suspicion, including items that can be used to ligature. The Duty Governor is required to ensure that the accommodation fabric check book has been signed before staff leave the establishment and to take appropriate action where necessary.
Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.
Sent To
- HMP Pentonville
- HMPPS
- Ministry for Justice
Response Status
Linked responses
1 of 3
56-Day Deadline
28 Apr 2026
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 27th March 2025 Assistant Coroner Saba Naqshbandi KC began an investigation into the death of Mujahid Adam who died aged 20, on the 21st March 2025 at University College Hospital, Euston Road, London NW1 following his transfer there from HMP Pentonville.
The investigation concluded at the end of a 7-day inquest, on 24th February, 2026 conducted by myself, Assistant Coroner Edwin Buckett sitting with a Jury at Bow Coroner’s Court.
The jury made a determination at inquest that the deceased died as a result of suicide with a number of possible contributory causes to his death.
The investigation concluded at the end of a 7-day inquest, on 24th February, 2026 conducted by myself, Assistant Coroner Edwin Buckett sitting with a Jury at Bow Coroner’s Court.
The jury made a determination at inquest that the deceased died as a result of suicide with a number of possible contributory causes to his death.
Circumstances of the Death
The Jury findings as to the circumstances of death were recorded in the Record of Inquest at Paragraph 3 as follows: “Mr Adam had a history of low mood and mental health issues.
He was facing a serious criminal charge and possible deportation.
He was the victim of a violent assault in a previous cell, and possibly fearful of transfer to another wing.
He made a suicide attempt by ligature on 19.2.2025.
He was placed on constant watch and under the ACCT process and he was getting regular assessments.
.
On 15.3.2025, no adequate observation was made on his cell between 11.42 and 12.18.
At 12.18, prison staff discovered him hanging in his cell.
The Code Blue signal was delayed, as was cutting him down.
Resuscitation was attempted and he went to University College Hospital.
He was declared dead on 21.3.2025.”
The conclusion of the Jury as to the death was recorded on the Record of Inquest at Paragraph 4 as follows:
“Mr Adam’s unstable mental health possibly contributed to his death.
There was a failure to perform observations at an appropriate frequency, in accordance with the ACCT policy.
There was a delay in calling Code Blue and cutting him down.
These matters possibly contributed to his death.
The cell’s condition possibly provided a greater opportunity to attempt suicide.”
He was facing a serious criminal charge and possible deportation.
He was the victim of a violent assault in a previous cell, and possibly fearful of transfer to another wing.
He made a suicide attempt by ligature on 19.2.2025.
He was placed on constant watch and under the ACCT process and he was getting regular assessments.
.
On 15.3.2025, no adequate observation was made on his cell between 11.42 and 12.18.
At 12.18, prison staff discovered him hanging in his cell.
The Code Blue signal was delayed, as was cutting him down.
Resuscitation was attempted and he went to University College Hospital.
He was declared dead on 21.3.2025.”
The conclusion of the Jury as to the death was recorded on the Record of Inquest at Paragraph 4 as follows:
“Mr Adam’s unstable mental health possibly contributed to his death.
There was a failure to perform observations at an appropriate frequency, in accordance with the ACCT policy.
There was a delay in calling Code Blue and cutting him down.
These matters possibly contributed to his death.
The cell’s condition possibly provided a greater opportunity to attempt suicide.”
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.