Inner North London
Coroner Area
Reports: 328
Earliest: Sep 2013
Latest: 3 Mar 2026
79% response rate (above 62% average).
Mujahid Adam
Response Pending
2026-0125
3 Mar 2026
HMP Pentonville
Ministry for Justice
HMPPS
Suicide (from 2015)
Concerns 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.
Sean Williams
Response Pending
2026-0105
20 Feb 2026
Serco Prison Transport Services
Metropolitan Police Service
Other related deaths
Concerns summary
A custody nurse failed to take vital signs before prescribing medication. Serco staff critically delayed first aid, didn't use emergency alerts, and couldn't provide their location to emergency services.