Inmate died by suicide after release from HMP Pentonville

Moses Hailemichel died by suicide on March 3, 2025, six days after his release from HMP Pentonville. An investigation by the Prisons and Probation Ombudsman found that delays and poor communication between the prison and the probation service contributed to his death.

Mr Hailemichel, aged 20, was released from the North London prison on February 25, 2025, following a second period of detention. On the day of his release, he was reportedly in a state of paranoia, refused to take his psychiatric medication, and did not sign his release paperwork. The Ombudsman concluded that while in custody, he did not show signs of being a suicide risk.

Communication Failures

The watchdog's investigation ruled that sentencing backlog issues meant Mr Hailemichel did not have an officer managing him before his release, despite documented mental health problems. Knowledge gaps emerged between the prison and probation services. His probation officer failed to disclose crucial information about his release address and his status under social services, while his social worker was unaware he was in prison.

Mr Hailemichel, an Eritrean national with limited English, had a history of mental and behavioural issues. The Ombudsman noted that he was never assigned an interpreter during his time in jail, which likely affected his engagement with staff. He had been remanded for possession of a knife in public and was classed as a medium risk to others.

He had been released on February 10 but was recalled shortly after for failing to attend a probation appointment. During his second stint, staff noted his challenging behaviour, though he had not harmed himself or expressed suicidal thoughts.

Release Planning Issues

A senior probation officer told the watchdog that sentencing calculation delays meant Mr Hailemichel lacked a Prison Offender Manager for both his periods at HMP Pentonville, a breach of guidelines. An alternative of admitting him to the prison's healthcare ward was discussed but never happened. His assigned probation officer intended to refer Mr Hailemichel to Crisis after his first appointment, but did not inform healthcare staff of his location or his involvement with social services.

The day after his release, Mr Hailemichel attempted to attack a nurse who was assessing his need for inpatient admission. Clinical staff determined he required planned intervention to prevent him from harming himself or others.

A mental health practitioner at HMP Pentonville referred him to the community mental health team via email, but received an automated out-of-office reply for urgent matters, with no phone call made. Mr Hailemichel did not attend his scheduled probation meeting. Police discovered he had taken his own life during a welfare check on March 3, 2025. His social worker informed the probation officer of his death two weeks later, but this information was not added to the service's case management system.

Ombudsman's Recommendations

Adrian Usher, Prisons and Probation Ombudsman, made several recommendations. These included ensuring interpreters are provided for patients who need them, developing a collaborative policy for pre-release planning for sentences under 12 weeks, and ensuring urgent concerns about prison leavers are addressed promptly. HMP Pentonville stated it had cleared its backlog and recruited more staff to its Offender Management Unit.

A Prison Service spokesperson said: “We have fully accepted the Prisons and Probation Ombudsman’s recommendations and are taking action to address the issues identified in the report.”

Mr Hailemichel was the first of two former inmates to die by suicide within two weeks of release from Pentonville since October 2023. The second individual was also released without referral to community mental health services.

What Happens Next

HMP Pentonville has stated it is acting on the report's findings, including ensuring probation practitioners share safeguarding information with relevant prison and healthcare staff. The prison's interpreter arrangements for inmates are already in place. The Prison Service has confirmed it is taking action to address the identified issues.