Kate Litman, a case worker at Inquest, a charity which supports bereaved families in the aftermath of deaths in prison, said there was currently no enforcement mechanism to compel prisons to implement the lifesaving, and often simple, measures coroners suggest.
“There’s really no way of us knowing if Pentonville is implementing the changes that the coroner recommended, because it seems to be the only way to make Pentonville answer is for there to be another death, where we raise the same concerns and ask the same questions,” she said.
Kate said coroners routinely issue Prevention of Future Death reports, but their recommendations are frequently not followed up.
“We see repeated failures from prisons to learn from their mistakes and to implement change.”
For Saroj, the most important outcome of the inquest was the detail added to Gareth’s death certificate, describing how the lack of care he had received in prison contributed to his death.
“One day when his children look back on everything that happened to their father, they will know that he was let down. He didn’t just commit suicide – he was driven to it,” she said.
“I don’t want any other mother to witness what I witnessed,” she added.
“I’ve seen dead bodies before, but they didn’t look the way Gareth looked. He looked like a horror movie lying in his coffin, completely in distress. You could tell he died in complete pain.”
She said the impact on Saroj and her daughter, Gareth’s sister, had been seismic.
“It was always the three of us. Our family unit is completely broken now, we’ll never be the same.
“I want his death to have meant something. That’s the only peace we would get.”
