Prison Cat B/C local YOI Key Concerns Identified Positive Findings

Pentonville

IMB Annual Report 2024 · Published 29 October 2024

HMP Pentonville, a Category B local prison, experienced significant challenges in the reporting year, marked by overcrowding with a population of 1,195 against a CNA of 909. The prison saw a 28% increase in violence and a 13% rise in self-harm incidents, alongside chronic issues with infrastructure, pest infestations, and limited time out of cell for prisoners. Staffing shortages impacted key services, and critical concerns included the lack of mental health secure beds and the unsatisfactory conditions of worship areas.
Population
1,195
Operational Capacity
1,205
CNA (Designed For)
909
131% occupancy
Avg Hours Out of Cell
2.0h/day
Deaths in Custody
2
prev: 1
Self-harm Incidents
610
prev: 540
ACCT Cases Opened
674
Prisoner Assaults
600
prev: 469
Assaults on Staff
180
Use of Force
895
prev: 798
Positive Findings
The Board noted positive improvements in Reception and Early Days in Custody. The Prisoner Platform Meeting was commended for its effectiveness and influence. There was also good care for transgender prisoners and successful organisation of religious festivals. New Models of Care improved mental health assessments, and the Neurodiverse Unit continued to function well. Good use was made of in-cell TV channels and faith-based publications, and the education programme in Pentonville was highlighted as a great resource.
Key Concerns
Safety
Inadequate completion of Assessment, Care in Custody and Teamwork (ACCT) documentation used in the care-planning process for prisoners identified as being at risk of suicide or self-harm remained an issue, with important elements regularly not completed and insufficient evidence of meaningful conversations. The ACCT process and its supporting documentation is a problem and contributed to these poor standards. It is overly complicated, illogically set out and should be revised.
Staffing
The Board observed that the Safer Custody department in the prison struggled to adequately fulfil its remit. This is due to management changes, time taken up by attending inquests and understaffing, particularly towards the end of the reporting year.
Safety
Violence levels increased by 28% on the previous reporting year and increased steadily over the last few months of the reporting year. The appointment of a Violence Reduction Officer meant that reasons for violence could be more easily identified. However, the officer was re-deployed at various times during the year which reduced the opportunity for thorough investigations and the identification of the causes of violence.
Estate/Conditions
The lack of privacy and cramped conditions cannot be said to be decent or humane. In addition, there are major problems with the fabric and infrastructure. The buildings, including cells, are porous to continual infestations of rats, mice, cockroaches and flies. Blitzes by Rentokil provided only temporary respite.
Estate/Conditions Repeated
The roof above the mosque is in a terrible state of disrepair and leaks. The Board believes that the large temporary tarpaulin over the mosque ceiling is an inappropriate fix for a space that has been allocated as a place of worship and the roof and ceiling should be repaired properly and promptly.
Regime/Time Out of Cell
The Basic level of the incentive scheme restricts the number of showers that a prisoner can take. This undermines decency and must not be included in the local incentives policy.
Mental Health
The lack of beds in secure hospitals has led to very unwell men remaining in the prison and men staying on the wings or in the care and separation unit (CSU) awaiting a place in the prison’s in-patient unit.
Regime/Time Out of Cell Repeated
Many prisoners spent around 22 hours a day locked in their cells. The Board considers that this an unacceptably long time to be locked away, reduces opportunities for rehabilitation, is inhumane and amounts to the warehousing of a significant proportion of Pentonville’s population.
Education/Purposeful Activity Repeated
Unreliable and late unlocking by wing staff remained a frustration for education tutors and valuable teaching time was lost. In late March, attendance was approximately 55% from an allocation of 75%.
Staffing Repeated
Additional demands have been placed on the Offender Management Unit (OMU) because of a flurry of government-imposed measures taken to manage the overcrowding in prisons. The additional work in identifying prisoners for relocation to other prisons, early release and changes to rules on home detention curfews have all placed extra work on an already fragile team without extra resource.
Equality/Diversity
Prisoners in a wheelchair do not have access to many areas of the prison, including some of the exercise yards. There are very few cells adapted to their needs. Pentonville is not a suitable prison to hold prisoners with reduced mobility.
Food/Catering
However, the main issue was a rat infestation in the main kitchen, particularly since November. Rat droppings, rat vomit and other excrement were regularly seen in the kitchen, and the service provided by Rentokil did not solve the problem, with a lack of an escalation plan when the problem persisted. This was a serious health and safety hazard which the Board considered senior management did not deal with in a sufficiently serious and timely manner.
Complaints/Property
The lack of confidence amongst prison staff in the value of referrals of more serious offences committed in the prison to both the Independent Adjudicator (IA) and the police.
Staffing
Key work has never had a chance to embed itself and limps along in a moribund state with some months better than others.
Other
The prison has therefore returned to the temporary Covid-19 arrangement (implemented to allow social distancing) of using the social visits hall for in-person visits in the mornings, resulting in a loss of confidentiality.
Board Commentary
Staffing
Staff shortages and redeployment issues significantly impacted the Safer Custody and Equality teams, hindering their ability to deliver support and conduct investigations. The Key Work scheme struggled to embed due to insufficient staffing. While Offender Management Unit (OMU) management addressed some shortages, additional government-imposed pressures strained the already fragile team without extra resources.
Healthcare
Pentonville's healthcare faced challenges including pharmacy staff vacancies, a national problem. The cessation of initial acknowledgements for prisoner healthcare applications led to communication issues and increased IMB applications. A significant concern was the lack of secure hospital beds, resulting in unwell men remaining in prison or awaiting inpatient unit places, with an average mental health transfer waiting time of 63 days.
Regime & Daily Life
A significant concern is the 22 hours per day many prisoners spend locked in their cells, which the Board considers inhumane and detrimental to rehabilitation. This is compounded by unreliable unlocking, leading to lost education time and low attendance. The incentive scheme's restriction on showers for Basic level prisoners undermines decency and is non-compliant with national policy. Constraints on job opportunities continued on the designated Vulnerable Prisoners Unit (VPU).
Applications to the IMB

Prisoners can apply to their IMB about any aspect of their treatment. This table shows application counts by category.

Category Current Previous Change
Accommodation (including transfers) 103 70
OMU 103 70
Property 103 70
Recommendations (10)
Other: 2 HMPPS: 4 Governor / Director: 4 2 repeated
Recommendation 1
What measures is the Minister planning to take to reduce overcrowding in the prison system, in light of the fact that the prison estate nationally is almost at capacity and projected to increase still further before additional spaces become available under the current prison building programme?
Other (minister) overcrowding
Recommendation 2 Repeated Prev. unaddressed
How can the Minister justify the lack of urgency by HMPPS to address the appalling state of the main mosque roof?
Other (minister) estate
Recommendation 3 Prev. unaddressed
The 2022 Prisoners’ Property Framework has yet to have any positive impact on the transfer of property between prisons. Will HMPPS commit to an evidence-based review of the Framework?
HMPPS other
Recommendation 4
The ACCT documentation (revised in 2022) is poorly drafted, overly complicated and many staff are not able to complete it adequately. Will HMPPS commit to an urgent review of this essential, potentially lifesaving, documentation?
HMPPS safety
Recommendation 5 Repeated Prev. unaddressed
Will HMPPS provide extra support to the OMU who are under unsustainable pressure from dealing with the multiple government-imposed measures taken to manage overcrowding alongside their business as usual workload?
HMPPS staffing
Recommendation 6
Growing numbers of prisoners accused or convicted of sex offences are held in Pentonville. Delivering a meaningful and rehabilitative regime to this vulnerable group safely is very challenging. Will HMPPS commit to delivering greater local support and a national strategy?
HMPPS safety
Recommendation 7
Will you commit to ringfence the work of the wider safer custody team, including in particular the Violence Reduction Officer and Equality staff?
Governor / Director staffing
Recommendation 8
Do you commit to remove the restriction on the number of showers that a prisoner on Basic can take on the grounds that it infringes the prisoner’s right to decency?
Governor / Director regime
Recommendation 9 Prev. unaddressed
Will you commit to reinstate auditing of the quality of responses sent by the prison to prisoner complaints?
Governor / Director complaints
Recommendation 10 Prev. unaddressed
What will you do to resurrect the important key worker scheme?
Governor / Director staffing
Other IMB Reports for Pentonville
2025 Published 2 Oct 2025 1,180 565
2023 Published 26 Sep 2023 1,140 487
2022 Published 24 Aug 2022 1,043 564
2021 Published 14 Sep 2021 966 556
2020 Published 9 Sep 2020 1,025 682
HMIP Inspections

Recent inspections by HM Inspectorate of Prisons for this establishment.

16 Mar 2026 IRP
16 Jul 2025 Urgent Notification
30 Jun 2025 Unannounced
11 Apr 2023 IRP
11 Jul 2022 Unannounced
PPO Fatal Incidents

Prisons and Probation Ombudsman fatal incident investigations for this establishment.

Gareth Chumber-Kelly
Self-inflicted · Report published
Rickie Poon
Self-inflicted · Report published
Solomon Bamidele
16 Nov 2023 · Natural causes · Report published
Prevention of Future Deaths Reports

Coroner PFD reports issued to this establishment.

Rickie Poon
· State Custody related deaths
Peter Campbell
11 Mar 2026 · This report is being sent to: HM Prison & Probation Service | Phoenix Futures | Practice Plus Group
Mujahid Adam
3 Mar 2026 · Suicide (from 2015)
Gareth Chumber-Kelly
9 Feb 2026 · State Custody related deaths | Suicide (from 2015)
Khairul Rahman
2 Jul 2021 · State Custody related deaths