Coroner Criticises Nurse in Pentonville Suicide Case

A mental health nurse's failure to read the medical records of Stephen Nuth, 51, meant they were unaware he had previously told another nurse he was hearing voices urging him to take his own life. Mr Nuth died by suicide in his cell at HMP Pentonville on September 24, 2025, two days after the check. The inquest into his death concluded in July 2026.

Senior Coroner for Inner North London, Mary Hassell, stated in a report published on October 13, 2026, that the nurse who checked on Mr Nuth failed to read his records beforehand. This oversight meant the clinician was unaware that Mr Nuth had been categorised as “at risk” of suicide. Had the records been reviewed, the coroner said, the safeguarding protocol for prisoners at risk of self-harm or suicide would have been triggered.

Systemic Failures at Pentonville

The coroner noted that Mr Nuth's electronic patient record also showed that an assessment care in custody and teamwork (ACCT) file had not yet been opened for him. This file is standard procedure for prisoners identified as being at risk. The North London NHS Foundation Trust (NLFT), which provides clinical staff to the prison, stated at the inquest that it had taken steps to prevent similar oversights.

Both the mental health nurse and the then-service manager accepted that Mr Nuth’s file should have been read prior to the mental health check. They suggested that the absence of mobile devices in jail could mean healthcare professionals do not always read notes before inmate checks. Ms Hassell concluded that the issue appeared to be a systems problem rather than solely the fault of an individual practitioner. She issued a Prevention of Future Deaths report to the NLFT, warning of the risk of similar deaths if action is not taken.

The Chief Medical Officer of NLFT acknowledged the coroner's concerns and stated the trust was revising its policy to stress the importance of reviewing records before assessments. However, the officer added that the trust recognised that in the prison's "busy and clinically acute environment," circumstances could prevent this, such as in emergencies. The mental health nurse involved was an agency worker who has since been placed under additional clinical supervision by their employer.

Previous Warnings Issued

A July 2025 inspection of HMP Pentonville had previously highlighted serious failures, occurring against a backdrop of three suicides in custody that year. The inspection report described the care for vulnerable prisoners as "appalling" and noted staff responsible for prisoners on constant watch were found asleep, reading, or absent. Government data indicates a total of four inmates died at Pentonville that year. A more recent report in April 2026 found that while "reasonable progress" had been made on prisoner safety, the application of ACCT case management for those at risk of suicide or self-harm remained inconsistent.