Inquest into Pentonville suicide forces NHS policy overhaul

The Senior Coroner for Inner North London, Mary Hassell, concluded in a report dated 13 October 2026 that a mental‑health nurse failed to consult the inmate’s medical file before a check two days prior to Stephen Nuth’s death, as reported by MyLondon. The omission meant the nurse did not see that Nuth had previously told another clinician he was hearing voices urging him to end his life. The coroner said the lack of record review left staff unaware that the prisoner had been flagged as “at risk” of suicide.

Inquest findings

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The inquest, which ended in July 2026, confirmed the death as suicide, according to MyLondon. Hassell highlighted that the inmate’s electronic patient record showed no ACCT (Assessment, Care in Custody and Teamwork) file had been opened, a step that would normally trigger a safeguarding protocol for those deemed at risk. She noted that the nurse and the service manager both accepted the file should have been read before the check, but argued that prison restrictions on mobile devices can impede record access. The coroner labelled the incident a “systems issue” rather than a single‑person failure.

Aside from the individual, this seems to be a systems issue.

Mary Hassell, Senior Coroner for Inner North London

Trust response

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The Chief Medical Officer of the North London NHS Foundation Trust told MyLondon that the organisation accepted the coroner’s concerns and is revising its policy to stress the importance of reviewing patient records before any mental‑health check. The CMO added that the trust recognises the pressures of a busy prison health environment, noting that emergencies may sometimes prevent full record checks. He also said the nurse involved was an agency worker now placed under additional clinical supervision.

Implications for prison safety

A July 2025 inspection of HMP Pentonville, cited by MyLondon, criticised the prison for serious safety failures, describing support for vulnerable inmates as “appalling”. The report noted that staff responsible for monitoring high‑risk prisoners were sometimes absent or inattentive. Although an April 2026 review said the prison had made “reasonable progress”, it warned that ACCT case management remained inconsistently applied. The coroner’s Prevention of Future Deaths report now urges the trust to ensure record checks become routine, aiming to reduce the risk of further suicides.