HMP Pentonville handed my son a death sentence

The inquest heard that when Gareth arrived at the prison, he was sent in with a suicide warning, which noted his history of self-harm and suicide attempts, and that he had told the court he would take his own life if he was sent to prison.

But this information was not acted on.

His mother said the inquest was told that important paperwork had been lost, and that this was not uncommon at HMP Pentonville.

"It led to my son's death ultimately, and he was not given the care and the safeguarding that he needed. He was very at risk," she said.

The lost paperwork was only one of a catalogue of prison failings found at the inquest: the prison also failed to provide Gareth with mental health support or a welfare call - to which all prisoners are entitled to within their first 24 hours of incarceration, according to prison guidelines.

After self-harming on his second day at Pentonville, Gareth was still not referred to mental health services but was placed under hourly observations. The inquest found these observations were not always carried out, despite having been recorded as having been done.

On the morning of his death, only four prison officers were working on Gareth's wing instead of nine. As a result, the wing was placed on lockdown.

One prison officer admitted to falsifying the entry which recorded the last time that Gareth was seen alive by prison staff.

The coroner also heard how the first two officers on the scene "panicked" and failed to provide any form of basic life support.

Following his death, Saroj saw the cell where he died.

"It was extremely small, completely inhumane for two men to be sharing," she said.

"At the end of the bunkbeds there was a piece of cardboard, separating the toilet. Gareth never sat still, he would have found that absolutely claustrophobic."

She added: "These people may have committed a crime, but they've already been punished, they've been sent to prison and had their liberty taken away. To be further punished once you're inside that prison is atrocious."

Saroj is now demanding the government urgently intervenes and close HMP Pentonville down.

"It is a Victorian prison with very old facilities. It's a completely disgusting place -
cockroaches, rats, mice. There's a lot of gang fare in there.

"My son was frightened. There's a lot of violence in the prison."

Pentonville is one of 31 Victorian prisons still in operation across England.

Structurally, it largely remains the same as when it was built 180 years ago. Originally designed to hold 520 people in single cells, it now has an operational capacity of 1,205, with two prisoners packed into each cell.

In recent years it has been beset with problems, with an inspection concluding last year that 44% of prisoners felt unsafe, external.

Crucially, it also found there was a lack of support for those who self-harmed, and inspectors found staff reading, asleep or entirely absent while they were meant to be supervising very vulnerable men.

In less than three years since Gareth's death, five more people have died by suicide at the prison.

One of those was Rickie Poon, a former Met Police officer. An inquest into his death found the Assessment, Care in Custody and Teamwork (ACCT) process used to support inmates at risk of self-harm or suicide was inadequate and had contributed to his death, as reported by Josef Steen at the Local Democracy Reporting Service.

The inquest into his death was the fourth Prevention of Future Deaths report sent to Pentonville governors this year, and follows the suicide of prisoner Mujahid Adam in 2025.

At Gareth's inquest, coroner Jonathan Stevens made a number of recommendations for Pentonville to follow to prevent future deaths.

He said it was "deeply concerning" that he was making the same recommendations that had been made following another death at the prison two years before.

"No lessons have been learnt at Pentonville prison, no procedures have been put in place to prevent these deaths," said Saroj.

"The prison has had so many warnings, and it does not change. 
That's why it needs to be closed down."

Kate Litman, a case worker at Inquest, a charity which supports bereaved families in the aftermath of deaths in prison, said there was currently no enforcement mechanism to compel prisons to implement the lifesaving, and often simple, measures coroners suggest.

"There's really no way of us knowing if Pentonville is implementing the changes that the coroner recommended, because it seems to be the only way to make Pentonville answer is for there to be another death, where we raise the same concerns and ask the same questions," she said.

Kate said coroners routinely issue Prevention of Future Death reports, but their recommendations are frequently not followed up.

"We see repeated failures from prisons to learn from their mistakes and to implement change."

For Saroj, the most important outcome of the inquest was the detail added to Gareth's death certificate, describing how the lack of care he had received in prison contributed to his death.

"One day when his children look back on everything that happened to their father, they will know that he was let down. He didn't just commit suicide - he was driven to it," she said.

"I don't want any other mother to witness what I witnessed," she added.

"I've seen dead bodies before, but they didn't look the way Gareth looked. He looked like a horror movie lying in his coffin, completely in distress. You could tell he died in complete pain."

She said the impact on Saroj and her daughter, Gareth's sister, had been seismic.

"It was always the three of us. Our family unit is completely broken now, we'll never be the same.

"I want his death to have meant something. That's the only peace we would get."