Cell checks missed on night Nikoloz Khuchua hanged himself at HMP Pentonville

Published: 13th May, 2011
by JOSIE HINTON

THE death of a man found hanged in his cell less than 24 hours after arriving at prison came “out of the blue”, an inquest jury was told.

Nikoloz Khuchua, who was originally from Georgia but lived in Seven Sisters Road, Holloway, was found dead by his cellmate at HMP Pentonville on September 10 last year.

During an inquest into his death this week, St Pancras Coroner’s Court was told the 35-year-old father had arrived at the Holloway prison the previous evening to begin a three-month sentence for shoplifting. He had given medical staff no indication he was at risk of harming himself.

But his suspended body may have been missed by an officer doing roll call checks, the hearing was told. 

On his arrival at prison, Mr Khuchua was seen by prison officers, three medical staff and had a substance mis-use assessment. Inmates at risk of harming themselves are monitored under an ACCT (assessment care in custody and teamwork) document.

But Mavis Sukhu, a nurse on F Wing, where prisoners with drug and alcohol dependency receive specialist care, said Mr Khuchua did not meet the criteria.

She told the inquest he was in “low mood” when he arrived at Pentonville but showed no signs he posed a risk to himself.

“He was very calm and quiet,” she said. “He understood everything I was saying and he answered all my questions. I asked if he was suicidal and he said no. He said he had no thoughts of self harm.”

Mr Khuchua was found dead at 8.10am the following day. Medical staff who rushed to his cell described his body as “pale”, “stiff” and “cold.”

During the two-day inquest, it emerged welfare checks which usually take place with first-night inmates were not undertaken as a nurse had not received a proper induction. This included a 6am check.

The last check of Mr Khuchua’s cell took place at around 6.45am during the morning roll call, where prisoners are counted by officers to check they are in their cells.

But coroner Dr Andrew Reid said the “body of evidence” suggested Mr Khuchua died before 6.45am.

Dr Reid said the missed welfare checks had no bearing on Mr Khuchua’s death.

Returning a narrative verdict, a jury ruled Mr Khuchua died “as a result of an act of self- harm by the suspension of a ligature while in prison custody.” 

In the absence of the jury, Mr Khuchua’s sister Katrina Raminishvili said: “There’s no evidence my brother was observed during the night though he mentioned that he was depressed.

“The body of evidence suggests he had been dead for three hours though officers described checking the cell in that time frame and noticed nothing unusual.

“The army of people couldn’t save one life.”