Dear Mr Stevens,

Thank you for your Prevention of Future Death Report (‘PFDR’) dated 9 February 2026 following the conclusion of the Inquest into the death of Gareth Chumber-Kelly who sadly died in July 2023 at HMP Pentonville.

As the Managing Director of Serco’s Justice and Immigration business, I am responding on behalf of Serco and Antony Kirby, Serco’s Group Chief Executive Officer to matters of concern that you have raised in the PFDR, in so far as they relate to Serco under the Prisoner Escort and Custody Services (PECS) contract. I am aware that you will share a copy of this response with Mr Chumber-Kelly’s family and I would like to express my sincere condolences for their loss. Every death in custody is a tragedy, and the safety of those detained and transported by Serco is our absolute priority.

I am grateful to you for bringing the matters of concern to Serco’s attention. However, before addressing those concerns, I feel obliged to express my surprise that a PFDR was issued against Serco in this case. As you will be aware Serco were not identified as an interested person in the Inquest, and were not given an opportunity to provide any evidence in relation to Mr Chumber-Kelly’s time in Serco’s custody to demonstrate that we not only complied with our obligations and followed the appropriate processes to keep Mr Chumber-Kelly safe, but also passed on all risk information to the receiving prison. You may not be aware that there are commercial and reputational implications for Serco if a PFDR is issued against us, and it seems particularly unfair for us to be subject to such implications without the opportunity to address the court’s concerns in advance of a PFDR being issued against us. However, I understand that the concerns only came to light at the very end of the Inquest, during PFD evidence from the Governor of HMP Pentonville and therefore anticipate that you may not have had the opportunity to raise them with Serco whilst the case was being prepared for Inquest, or during the Inquest itself.

It is noted that the jury’s narrative conclusion into Mr Chumber-Kelly’s death confirmed that his medical history and immediate circumstances posed a clear risk to his life and that this risk was clearly identified outside the prison. However, due to several failings on the part of the prison, which were listed by the jury, the risk was not addressed. It is further noted that a Suicide and Self-Harm warning form (SASH) was completed by a mental health practitioner whilst Mr Chumber-Kelly was in Serco’s custody and that this very important document was handed over by Serco staff to prison reception staff, therefore fulfilling Serco’s duty of care obligations to Mr Chumber-Kelly at that point. I understand that the prison staff accepted during evidence that this document had been received, reviewed and that the document confirmed that Mr Chumber-Kelly had stated that he would kill himself if he was remanded to prison. The known risks were therefore communicated to the prison, to allow them to take action to keep Mr Chumber- Kelly safe.

However, I note that your PFDR states that for reasons that were not established, there was no evidence that a hard copy of a Liaison and Diversion report completed by the mental health practitioner was with the documentation that was received by prison staff on Mr Chumber-Kelly’s arrival at Pentonville. If Serco had been granted IP status it is of course possible that evidence could have been provided in relation to the missing document. However, it is also noted that the court heard evidence from prison staff that the reception process at HMP Pentonville was inefficient and slow and that paperwork would sometimes be lost. Having not had the opportunity to provide representation, or even be present at the Inquest, it is not

Serco Justice & Immigration Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire, RG27 9UY United Kingdom T: +44 (0)1256 745 900 | F: +44 (0)1256 744 112 | www.serco.com Serco Group Plc, a company registered in England and Wales No. 2048608 Registered Office: Serco House, 16 Bartley Wood Business Park, Bartley Way, Hook, Hampshire RG27 9UY, United Kingdom

clear whether their evidence was that the documentation could sometimes be lost as a result of the stated inefficiencies, or alternatively as a result of any failings on the part of Serco PECS staff. However, it is noted that there is no mention of the prison’s reception staff being critical of Serco in your PFDR, and that the jury made no findings of any failings on Serco’s part. It appears from the PFDR that the first mention of any issue involving Serco was when the Governor at the prison was giving PFD evidence. It is understood that he also confirmed that there had been no dialogue with Serco in relation to the ‘missing documentation’.

The court may not be aware that Serco PECS conduct monthly stakeholder meetings with HMP Pentonville, where performance updates, emerging issues, complaints, and other relevant matters are discussed and follow-up actions are agreed. Clearly these meetings would have been the correct forum for such suggested concerns about missing documentation to be raised. To our knowledge, there are no confirmed instances of missing paperwork being escalated to Serco staff by the Prison’s management team in these forums, either before or after Mr Chumber-Kelly’s death. I will however ensure that the Serco representative who regularly attends the stakeholder meetings at HMP Pentonville raises this issue at the next meeting, so that a full and constructive discussion can take place, and any remedial concerns, if there are any, can be resolved.

Thank you again for bringing your concerns to my attention. I can assure you that Serco is fully committed to keeping the often-vulnerable individuals in our care safe and well, and I hope you are reassured by the response to the issue raised.

If I can be of any further assistance, please do not hesitate to contact me.

Dear Mr Stevens,

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR GARETH CHUMBER- KELLY

Thank you for your Regulation 28 report of 9 February 2026 following the inquest into the death of Gareth Chumber-Kelly at HMP Pentonville on 17 July 2023. 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 Chumber-Kelly’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 reception process at HMP Pentonville, the training of staff in relation to self-harm and suicide risk management and mandatory basic life support.

HMP Pentonville has introduced a digital induction passport to consolidate key risk information from paper records into a secure electronic format. This enables relevant information to be accurately captured, stored, and shared between departments, reducing the likelihood of omissions or data loss during the induction process.

To strengthen oversight of early days in custody, the prison has appointed a Head of Early Days with specific responsibility for the reception function. As part of their remit, they are leading a comprehensive review of reception procedures to identify any aspects, such as documentation handling, that may require improvement and to implement any necessary changes.

In addition, the group safety team conducts regular early days exercises, which replicate a prisoner’s arrival and induction experience. These assurance activities are used to test the effectiveness and consistency of the reception process in practice, and to identify areas where further improvements may be required. These combined measures are intended to strengthen risk information management, enhance operational oversight, and support continuous improvement of the safety and experience of those entering HMP Pentonville.

The Prisoner Escort and Custody Services (PECS) team within HMPPS recognises the importance of the timely and accurate transfer of risk and safeguarding information and treats this as a matter of serious operational priority. Responsibility for the creation, maintenance and clinical transfer of healthcare and associated risk information rests with qualified medical professionals. In this case, Liaison and Diversion (L&D) services are responsible for ensuring that relevant records are effectively shared with receiving prison healthcare teams. The PECS contracts do not place responsibility on PECS suppliers for the physical transfer of hard-copy medical or risk documentation between courts and prisons.

Following the implementation of the Book a Secure Move (BaSM) system, the PECS Contract Management Team has ensured that digital Person Escort Records (DPERs) are available for all prisoners moved by PECS suppliers between courts, prisons and police stations. Recent system enhancements enable authorised professionals, including medical practitioners and L&D services, to update a prisoner’s DPER directly following assessment. These updates are visible to receiving establishments once the prisoner is booked in from court or prison, prior to arrival.

This digital capability significantly strengthens the effective, safe and timely transfer of critical risk information across the criminal justice system, reducing reliance on hard-copy documentation and mitigating the risk of information loss.

With regards to your training concerns, 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 to officers. Additionally, all band 4 staff at HMP Pentonville have now received the Assessment, Care in Custody and Teamwork (ACCT) case review training, which equips them with the skills to be able to provide prisoners at risk of suicide with holistic and person-centred support in their role as ACCT case coordinators.

Nationally, all new prison officers receive mandatory emergency first aid training, including instruction in cardiopulmonary resuscitation, as part of their foundation package. To ensure that there is a sufficient level of provision required for an effective emergency response, every prison is required to conduct a first aid needs assessment in accordance with the first aid at work regulations. Within current HMPPS policy, these assessments are required to account for the needs of prisoners whilst in custody and individuals on probation.

More widely, HMPPS develops staff capability through refresher courses and communication packages. Materials, including instructional videos, have been developed and are available to staff through E-learning platforms to update and maintain their first aid knowledge and skills. These provide practical guidance on what to do in several potential scenarios that staff may encounter in the course of their duties.

The Pentonville Speed School will support this work by utilising Physical Education Instructors, who are qualified first aid trainers, to deliver basic life-saving skills to staff, including training in CPR. These short, practical sessions will ensure that staff receive essential refresher training and thereby increasing their confidence when responding to medical emergencies. In addition, HMP Pentonville is promoting the first aid at work course and encouraging wider staff participation to ensure that key areas of the establishment maintain sufficient qualified first aiders.

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.