An investigation found prison and probation staff did not properly prepare for Moses Hailemichel’s release from jail
A 20-year-old man who took his own life less than a week after being released from HMP Pentonville was failed by delays and poor communication between the prison and the probation service, an investigation has found.
Mr Moses Hailemichel died on March 3, 2025, six days after he completed his second stint in the North London prison, and just over a month after he was first remanded there for possession of a knife in public. On the day of his release, Mr Hailemichel was in a state of paranoia and had refused to take his psychiatric medication or sign his release paperwork.
The Prisons and Probation Ombudsman concluded that while in custody he did not show signs he was a suicide risk. But the watchdog’s investigation ruled that a sentencing backlog and communication failures had left the inmate without an officer managing him before his release, even though his mental health problems were documented.
Knowledge gaps later arose between the prison and the probation services by the time he was released. His probation officer notably failed to disclose important information about his release address, and the fact that he was under the care of social services. Meanwhile, his social worker had no knowledge that he was in prison.
A care leaver, Mr Hailemichel was an Eritrean national who spoke limited English and had a history of mental and behavioural problems due to his use of cannabinoids. His offence had led him to be classed as of medium risk to others. The prisoner was “aggressive and intimidating” towards nurses who tried repeatedly to assess his mental health.
Neither prison nor healthcare staff knew he was a care leaver or had been allocated a social worker, and while in jail he was never assigned an interpreter. “This likely affected Mr Hailemichel’s ability and willingness to engage and an interpreter would have ensured that he understood and was able to communicate more effectively with staff,” the watchdog ruled.
Two stints in prison
Mr Hailemichel was initially released on February 10 but was recalled back to HMP Pentonville soon after for not turning up to his first appointment with his probation officer. During his second stint, several prison staff found him still reluctant to engage as he continued to exhibit “challenging” behaviour in custody. Though prison and healthcare staff were concerned for his wellbeing, he had not harmed himself or expressed suicidal thoughts.
Though staff determined he would be released on February 25, a senior probation officer told the watchdog there had been sentencing calculation delays due to a backlog of cases which led to Mr Hailemichel going without a Prison Offender Manager (POM) in place for each of his stints at HMP Pentonville. This breached HM Prison and Probation Service (HMPPS) guidelines. An alternative was discussed that he be admitted to the prison’s healthcare ward, but he was never transferred.
His assigned probation officer, meanwhile, said he would refer Hailemichel to Crisis after he attended his first probation appointment upon release, but did not tell the nurse where he would be or that he was under the care of social services – a fact he gathered from the prisoner’s social worker.
The next day, the “paranoid” and “very angry” Mr Hailemichel tried to attack a nurse who was trying to review his need for inpatient admission. Clinical staff judged that he needed planned intervention to safeguard him from harming himself and others.
After his release on February 25, a mental health practitioner at HMP Pentonville referred him to the community mental health team by email but received an automated out-of-office message suggesting that contact be made over the phone for urgent matters. No phone call was made.
Mr Hailemichel did not attend his scheduled probation meeting. On March 3, police were alerted for a welfare check at his accommodation and discovered he had taken his own life. However, the social worker informed the probation officer of this two weeks later, but the information was never uploaded to the service’s case management system.
Prison efforts ‘recognised’
The case reviewer concluded that the prison’s release team should have phoned community mental health services as soon as they received an out-of-office email.
Adrian Usher, Prisons and Probation Ombudsman, made a string of recommendations in light of Mr Hailemichel’s suicide, including that the prison’s healthcare boss ensure that interpreters are arranged for patients whose records suggest they need one.
He also recommended the need for a “collaborative” policy to support pre-release planning for sentences shorter than 12 weeks, and ensure that urgent concerns about prison leavers be completed where possible. HMP Pentonville said it had now cleared the backlog and had recruited more staff members to the Offender Management Unit.
“While the delay in Mr Hailemichel’s sentence calculation resulted in him not being allocated a POM, we recognise that Pentonville are addressing this issue,” Mr Usher said.
HMP Pentonville said it had acted on the report’s findings, including ensuring probation practitioners share safeguarding information with relevant prison and healthcare staff about whether a prisoner is known to social care services. The prison’s interpreter arrangement for inmates is already in place.
A Prison Service spokesperson said: “We have fully accepted the Prisons and Probation Ombudsman’s recommendations and are taking action to address the issues identified in the report.”
Mr Hailemichel was the first of two former inmates who took their own lives within two weeks of their release from Pentonville since October 2023. The watchdog noted that the second man, unnamed, was also set free without being referred to community mental health services.
His death in March 2025 preceded a damning report into the prison’s conditions, published in July that year, which discovered many inmates had been kept there after they should have been freed because staff failed to calculate sentences accurately.
Got a story? Email josef.steen@reachplc or @jslondonldr on X.
Stay in the loop with the latest North London news. Sign up to our MyNorthLondon newsletter HERE for daily updates and more.
