Isaiah Olugosi: Prevention of Future Deaths Report
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Date of report: 24/02/2025
Ref: 2025-0106
Deceased name: Isaiah Olugosi
Coroners name: Richard Furniss
Coroners Area: West London
Category: State Custody related deaths | Suicide (from 2015)
This report is being sent to: HMP Wormwood Scrubs
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: [REDACTED], Governor of HMP Wormwood Scrubs | |
| 1 | CORONER I am Richard Furniss, HM Assistant Coroner for West London |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made |
| 3 | INVESTIGATION and INQUEST On 1 April 2022 an investigation was commenced into the death of Isaiah Adekunle OLUGOSI. The investigation concluded at the end of the inquest on 21 February 2025. The conclusion of the inquest was Suicide 1a Asphyxia 1b Hanging 1c II |
| 4 | CIRCUMSTANCES OF THE DEATH The Deceased hanged himself in his prison cell overnight on 27/28 March 2022. The jury found that this was suicide. He had spoken to his wife at about 2100 hours on 27 March 2022. She believed he was suicidal and likely to take his life. She, and Cambridgeshire Police and the Metropolitan Police, were all unable to contact he prison by telephone to warn them. It later transpired that this was because the calls were being diverted to an unmanned or obsolete number. The Deceased’s wife drove from Cambridge to the prison, two hours away. She stood outside the main gate for some considerable time, banging on it, calling out and pressing a buzzer which promised to connect her to an intercom through which she could speak to prison staff. The intercom was out of action and had been for several years. In the result, the Deceased’s wife and the police could not contact the prison all night During that night, the Deceased took his life. |
| 5 | CORONER’S CONCERNS During the course of the inquest the evidence revealed the following matter giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTER OF CONCERN is as follows. – The buzzer/intercom system must have been provided because it was thought important to provide that additional means of communication between the prison and the outside world. In this case, a working system would have enabled the Deceased’s wife to warn the prison of his impending suicide. This could happen again in the future if there was another problem with the telephone system during the night state. It is difficult to understand why the buzzer/intercom system has not worked for several years. There was evidence that it is irreparable. But the proposed solution appeared to be either to leave it as it is (still not working) or to remove it altogether. The jury found that the failure to provide a working buzzer/intercom system was a failure. It is a matter of concern that the prison/the Ministry of Justice still considers that it is unnecessary. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you, [REDACTED], Governor of HMP Wormwood Scrubs, have the power to take such action |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 21 April 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person, [REDACTED](via her solicitors Messrs Hodge, Jones and Allen), who is the Deceased’s wife. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. |
| 9 | 24 February 2025 Signature Richard Furniss, HM Assistant Coroner for West London |