Jury finds multiple failures in death of a man remanded to Pentonville
Peter Campbell died on the 8 October 2024 five days after taking a substance suspected to be a synthetic cannabinoid and collapsing in his prison cell on the 3 October 2024 in HMP Pentonville. The jury heard that Peter was a vulnerable prisoner who had multiple Code Blues during his time in remand. The jury also heard that two safeguarding referrals were sent after Peter was taken to hospital on the 18 September 2024 following a code blue from suspected drug overdose. One of these safeguarding referrals set out concerns that Peter may have been used by other prisoner to test the potency of drugs within the prison. The jury heard that Peter had been discussed in a safeguarding meeting but at the time of his death, action had not been taken. The jury also heard that a drug recovery worker was the last healthcare worker to see Peter before his fatal collapse from drugs and did so two days beforehand, but that there were a number of gaps in his care.
Following a 6 day inquest in Inner North London, the jury found that there were a number of failures by the prison and prison healthcare, namely:
- There was a failure to prevent drugs from entering the prison.
- There was a failure from drug and alcohol services to provide a meaningful interaction with Peter following a serious drug related incident on the 18 September 2024, for which he required resuscitation.
- There were reports that Peter was likely testing new batches of synthetic cannabinoids within the prison, and there was a failure to act on this intelligence.
The Senior Coroner made a Prevention of Future Deaths Report under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009 and Section 28 of The Coroners (Investigations) Regulations 2013. The report outlines that the jury determined that the death was drug related and that they returned a narrative. The Coroner outlined her concerns to HMPPS and Pentonville with respect to the availability of drugs in the prison. She outlined that drugs have ´infiltrated the prison population with enormous reach and with potentially devastating consequences for the prisoners themselves and for others – there is a risk of prisoners leaving prison in a worse state than when they went in…´ The Coroner also outlined that the ´mass availability of drugs persists without abatement. This is not in any way peculiar to Pentonville, but Pentonville is an exemplar´. The Regulation 28 report was also addressed to prison healthcare and the prison substance misuse teams in relation to the gaps in Peter´s care provided by a drug recovery worker.
Keio Yoshida of the Doughty Street Chambers Inquests and Inquiries Team represented the family of Peter Campbell, instructed by Nina Meyer of Saunders Law.
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