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Published: 30 March 2007

Paul Calvert pictured with wife Marianne, sons Joe and Daniel and his mother Gwen
‘Systematic failures’ led to prisoner’s suicide in his cell

Ombudsman calls for reforms after inquest is told how inmate was ignored

A PRISON ombudsman has demanded tough reforms at Pentonville after “systematic failures” led to the suicide of a vulnerable inmate.
It follows a week-long inquest that heard how guards at the jail, in Caledonian Road, Holloway, played backgammon with an inmate unaware that Paul Calvert was hanging dead in his cell after staff had tampered with emergency alarms.
St Pancras Coroner’s Court heard Mr Calvert, 42, who had a history of self-harm and depression was allowed to keep his belt, which he used to kill himself in October 2004.
Last night (Thursday), his mother, Gwen, told the Tribune she was considering suing the Prison Service over its “appalling failures”.
“My son went to prison to lose his liberty not his life,” she said.
The jury inquest heard how Mr Calvert, who was in prison for breaching parole, pressed his alarm, before walking to the opposite side of his cell, where he climbed the pipes, attached his belt to the window bars and hanged himself.
The emergency buzzers were taped down and muted so wardens could not hear them.
The inquest heard that wardens relied on other prisoners to listen out for the alarms and alert them.
A majority jury ruled yesterday father-of-two Mr Calvert’s death at Pentonville followed “systematic failures, incomplete paperwork, lack of communication, disablement of cell bells and breach of security”.
He had been sent back to jail after breaching his parole following a fight with his girlfriend.
Coroner, Dr Andrew Reid, told the court: “Mr Calvert was known in Pentonville by a number of other inmates and views were expressed about whether he was depressed or if he had a tendency to use the system, to say the right words, or to do something to have a form opened (marking him as at-risk) so he would have more attention from officers.”
It also emerged in court that a telephone reception blackspot meant that, after wardens found the body, they had to run from the fifth-floor cell to the second floor to call 999.
Prisons Ombudsman Lorenzo DelGuardio was brought in to investigate the catalogue of failures that contributed to Mr Calvert’s death, publishing a list of 15 recommendations.
He called for a review of the checks on the emergency bell system, saying it was “clearly inadequate”.
Mr DelGuardio added: “The governor should remind staff in the strongest terms that any tampering with the cell bell alarm system is both potentially illegal and potentially life-threatening and might result in disciplinary action.”
Former prisoners testified how warden Steven Cummings played backgammon with inmate Sean Hart, while a second warden watched.
Mr Cummings denied playing the game but said he had touched some of the backgammon pieces.
He did, however, admit sending a prisoner to check Mr Calvert’s cell, after another inmate spotted the emergency light was on. It is not known exactly when Mr Calvert pressed his emergency buzzer. The inquest was told the emergency alarm had been taped down and muted for months after officers found it “annoying”.
Calls for assistance, the jury was told, were often abused by inmates, who treated it as “room service” asking for late-night toilet paper, sugar and cigarettes.
Instead of being answered by guards, they were answered by “trusted” inmates.
Crucially, details of Mr Calvert’s self-harming from his previous sentence at Pentonville were never provided when he was admitted.
Former inmate Fred Leer, who had become friends with Mr Calvert, said: “Many officers couldn’t be bothered to answer every alarm so we inmates would do it.”
Mr Calvert’s mother, Gwen, said: “My son’s death left me and the family heartbroken.
“The pain doesn’t ease as time passes.
“He was in a vulnerable state with a history of suicide attempts and wasn’t given the care he was owed.
“The evidence showed a number of appalling failures by Pentonville and its staff which lead to my son’s death. The officer ignored his cell alarm for 25 to 30 minutes while he played backgammon.
“Had someone got to him in three to four minutes, he may not have died.
“The jury found some systematic failings on the part of the prison service but I was disappointed they weren’t given the opportunity to say whether my son’s death was contributed to by neglect on the part of the prison system.”
A Prison Service spokesman said: “The recent inquest into the tragic death of Paul Calvert highlights and reiterates the duty of care we have for all prisoners at HMP Pentonville. We wish to express our sincere condolences to the family and friends of Paul Calvert at the end of what’s been an emotional and difficult period.
We have fully accepted the Ombudsman’s recommendations and have worked hard to ensure we’ve dealt with the issues that were raised.
“We recognise we need to learn lessons from this terrible tragedy. Our current practices and systems have a proven record. We have not had a self-inflicted death at Pentonville for over 18-months. We do, however recognise that we must continue to deliver full support and care to our prisoners and are continually learning and developing new systems to ensure the safety of those who we keep in our care.” The Crown Prosecution Service has investigated the case but will not be initiating criminal proceedings.
Verdict: Misadventure



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