‘HMP Pentonville sentenced my son to death’

Kate Littman, caseworker at Inquest, a charity that supports families of those who die in prison, says there is currently no enforcement mechanism to force prisons to carry out lifesaving work, and regulators often take simple measures.

“Obviously there’s no way of knowing if the Pentonville coroner has implemented the changes because the only way Pentonville can respond is if there’s another death where we raise the same concerns and ask the same questions,” she said.

Cate said coroners regularly issue reports to prevent future deaths, but their recommendations are often not followed.

“We see repeated failures in prisons to learn from their mistakes and implement change.”

For Saroj, the most important outcome of the inquest was the detail added to Gareth’s death certificate, detailing how the lack of care he received in prison contributed to his death.

“One day when the children look back on everything that happened to their father, they will know that he was angry. He just didn’t kill himself – he was driven there,” she said.

“I don’t want another mother to witness what I saw,” she added.

“I’ve seen corpses before, but they’ve never looked like Gareth. He looks like a horror movie guy lying in a coffin, completely depressed. You can tell he’s completely died of pain.”

The effect on Saroj and her daughter, Gareth’s sister, was seismic, she said.

“It’s always been the three of us. Our family unit is now completely broken, we’ll never be the same.”

“I want his death to have meaning. That’s the only peace we’ll get.”