The Independent London Newspaper


Coroner: ‘Chaos’ as nurse tried to resuscitate Pentonville Prison inmate

Pentonville Prison

Pentonville Prison

Published: 2 December, 2016

SHARP criticism has been levelled at a private healthcare company after a death at Pentonville Prison – for the third time this year.

Shocking footage from inside Pentonville emerged this week showing a nurse unable to provide proper resuscitation to an inmate who had hung himself.

It comes as yet another inmate took their own life inside the Caledonian Road prison. Vilhemas Borketas, 23, from Rainham in Essex, was found hanged in his cell last Monday. He had pleaded guilty to attempted robbery at Wood Green Crown Court in July and was jailed for 10 months.

At a St Pancras inquest this week, coroner Mary Hassell described a scene of “chaos” as healthcare staff attempted to revive Tedros Kahssay, who hanged himself in January.

The first nurse on the scene did not understand the difference between the prison’s emergency codes and did not check whether the inmate was alive before starting life support.

Ms Hassell is to lay out her concerns to Care UK, which provide healthcare services at the prison, for the third time this year in the form of a Prevention of Future Deaths (PFD) report.

She has already noted “significant failures” by Care UK staff in the case of Terence Adams, who killed himself in November last year. Ms Hassell also sent a PFD report to the company listing eight concerns after an investigation into the death of Samuel Blair, who was found hanged by his shoelaces in August last year.

A jury at the inquest into the death of Carl Foot also said failings by medical staff contributed to his death last year.

Care UK won the contract to provide healthcare, including mental and physical health,  at Pentonville in 2014. Healthcare was previously provide by the Whittington Hospital. 

The Care Quality Commission said the Whittington was meeting the required standards after an inspection in 2013, but the watchdog has not reviewed Care UK’s service since it took over.

A joint inspection by the CQC and Her Majesty’s Inspectorate of Prisons is to take place in January.

Mr Kahssay, 28, was charged with killing 32-year-old Mambero Ghebreflafie at a hostel for homeless people in Winchmore Hill just before Christmas 2015. She was pregnant and the baby did not survive. An inquest in February found that Ms Ghebreflafie was unlawfully killed.

Mr Kahssay was last seen alive by a prison officer around 8pm on January 18 during a cell check and was found hanged at 5am the next morning.

The first paramedic on the scene said CPR was “ineffective”, but said Mr Kahssay had been dead before staff started life support. When pressed by


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