An inquest into the death of a man who was found hanged in his prison cell at Wormwood Scrubs found that there was inadequate training to assess the risk of vulnerable prisoners on July 4 (Monday).

Olawale Adelusi, 41, who was an internet trader, was found hanging in his cell at the prison on November 3 2014 and died 10 days later at St Mary's Hospital in Paddington.

He was put on remand at Wormwood Scrubs after a hearing at Uxbridge Magistrates' Court following his arrest at Heathrow Airport on October 28 2014 for possession of fake documents.

The jury at an inquest into his death at West London Coroners Court returned a misadventure verdict, recording that Mr Adelusi died as a result of pneumonia and hypoxic ischaemic brain injury and hanging.

But they also concluded that Mr Adelusi's death was caused by contributing factors, including failure of transfer of information and documentation by the prison and healthcare authorities at each stage, due to communication failures and inadequate training.

The jury, which consisted of eight women, also concluded that a number of factors also contributed to Mr Adelusi's death, which included the following:

  • Communication and recording failures between Hillingdon Hospital, Met Police, Uxbridge Magistrates Court, SERCO and Wormwood Scrubs prison regarding risk

  • Inadequate training to access risk of a vulnerable person by Wormwood Scrubs prison officers and health care

  • Inadequate mental health provisions for detainees across the system

  • There was an inadequate response to an emergency situation

West London Coroner's Court in Fulham heard there was 'chaos' in the prison when Mr Adelusi was found hanged

The inquest heard on June 20 from a witness from a custody officer at Heathrow Airport who told the court that Mr Adelusi behaved unpredictably whilst in custody and refused to answer risk assessment questions.

Sergeant Helen Murray also told the court how Mr Adelusi had tried to strangle himself with a t-shirt while he was in custody at Heathrow airport.

On its fifth day, the inquest heard officers at Wormwood Scrubs give evidence about the moments leading up to Mr Adelusi's death , with officers reporting the emergency to the control room using a code system the operator did not understand.

The inquest began with a statement from Mr Adelusi's wife, Stella, telling the jury how he was a family man and wanted to move to Canada in order to give his children a better upbringing.

A Prison Service spokesperson said: "Our thoughts are with the family and friends of Olawale Adelusi.

"The safety and welfare of people within our custody is a top priority and we take our duty of care to them extremely seriously.

"We accepted the recommendations of the Prisons and Probation Ombudsman’s investigation in this case and we will carefully consider the inquest findings to see what further lessons can be learned."