- A Jury found that Mohammed Amin Azizi died from heart failure due to malnutrition, Crohn’s disease and self-neglect whilst serving time at HMP Norwich days before he was due for release
- He reported that Prison food made his Crohn’s symptoms worse, and he started to refuse medication, food and treatment whilst under the care of the Prison.
- There were concerns about Mohammed’s mental state and various professionals assessed his capacity to make decisions about his treatment.
- Area Coroner Mrs Samantha Goward also makes a Prevention of Future Deaths Report to Norwich Prison regarding “recreated” suicide document.
- Nelsons has been supporting the family who raised serious concerns about Mohammed’s care and had requested for an early release
A JURY at Norfolk Coroner’s Court concluded on 25 April 2024 that the death of a 32-year-old man while serving a custodial sentence, was due to heart failure, malnutrition and Crohn’s disease contributed to by self-neglect. Mohammed Amin Azizi, known to his loved ones as Mo, died at the Norfolk and Norwich University Hospital on 15 May 2023, while serving time at HMP Norwich. He had previously been at HMP Chelmsford, and then HMP Highpoint, but was moved to the healthcare wing at HMP Norwich in August 2022 due to his declining physical health.
Mohammed had Crohn’s disease since 2012 but was able to manage his condition and live a normal and active lifestyle prior to going into Prison. In Prison, he complained to staff and to his family about how the Prison food aggravated his condition.
The family told the Court that Mohammed had no previous history of mental health problems but experienced a sudden and serious psychological decline in the months leading up to his arrest and was even sectioned under the Mental Health Act for assessment before going to Prison. Whilst in Prison, he reported a number of bizarre beliefs to his family, Prison Officers and healthcare staff. He also showed signs of being paranoid and did not trust anyone. Mohammed’s family strongly believe that his concerning pattern of thinking impacted his decision to refuse treatment and food.
The Court heard that Mohammed was assessed by psychiatrists on a number of occasions but was deemed not to have a diagnosable mental health disorder. He was prescribed an anti-psychotic medication, but this was stopped two weeks later after he refused to take it. The GP working on the healthcare wing at the Prison also thought that Mohammed may have been suffering from a severe mental health disorder in March 2023.
As Mohammed’s physical condition deteriorated in Prison, he suffered from extreme abdominal pain, rectal bleeding, blood in his vomit and lost around half of his body weight. Despite this, he refused surgical intervention for a perforated bowel as he was convinced he could wait until he left Prison to have surgery.
While at HMP Norwich, Mohammed was admitted to the hospital several times because of the decline in his physical health. In April 2023, he went in for the final time and sadly died a few weeks later.
In October 2022, Mohammed’s family also spoke with the then Head of Suicide and Self Harm at HMP Norwich about making an application for Mohammed to be released from the Prison early on compassionate grounds but this was ultimately not submitted at that time as the criteria was not met. An application was eventually put through on 12 May 2023 – just three days before Mohammed’s death, given the serious risk of death at this time.
The inquest took place from Wednesday 17 April to 25 April with a Jury present. The Court heard evidence from staff on the healthcare wing, the mental health in-reach team and Prison Officers all involved in Mohammed’s care.
Following the Jury’s conclusion, Coroner Samantha Goward issued a Prevention of Future Deaths Report (PFD) after the Prison failed to explain why there were two versions of a document with the same log number in existence, which related to Mohammed’s suicide and self-harm risk in Prison.
During Mohammed’s time at Norwich Prison, he was placed on an Assessment, Care in Custody and Teamwork (ACCT) on two occasions. ACCT documentation is designed to monitor and support those at an acute risk of suicide and self-harm. In March 2023, an ACCT was opened because of concerns Mohammed was not eating or drinking and his refusal to attend the hospital for life-saving treatment. This ACCT was kept open for around 12 hours.
The March 2023 ACCT was disclosed to the Court by Norwich Prison ahead of the inquest. However, evidence was heard from two Prison Officers that they had never seen this version of the ACCT document. The document appeared to include their signatures, however, both Prison Officers said these signatures were not made by them. In fact, after one of the witnesses came to learn about the two documents, she said she was told by senior staff not to mention this whilst preparing for the inquest.
The Coroner said she had “obvious and serious concerns” about the existence of two ACCT documents which two witnesses said includes their signatures but did not sign. She also raised concerns for the lack of explanation for this.
In giving her ruling, the Coroner explained that “inquests and Prison Ombudsman investigations happen after the very worst and someone has died”. She said that if the Coroner and the Prison Ombudsman investigations are hampered by “a lack of full disclosure and potentially recreated and inaccurate documents”, there are concerns that the same thing could happen again and poses a risk of future deaths in Prison. She also stated she did not have enough evidence from Norwich Prison to understand how and why this happened. The Coroner raised that had the officer not been called to give evidence and her statement simply read, the Court would not have been aware of a second ACCT document or the issues surrounding it. A formal report was required due to the seriousness of the situation.
Following the inquest, the family gave the following statement:
“Mohammed was a much-loved member of our family, he was kind and generous to all his friends and family. He always tried to bring fun and joy to our lives. We miss him dearly and we will always keep his memory alive.
“We thank both Shrdha and David for their work on this highly complex case, and ensuring our concerns were voiced to the Court. We were shocked to hear about the use of a recreated Prison document that related to Mo, and how this was handled by the Prison and not disclosed to the Court or to the Prisons and Probation Ombudsman. We are pleased the Coroner decided to write a Prevention of Future Deaths report in relation to this, and that investigations will take place into how and why this happened, to ensure other families do not experience this in future.”
Shrdha Kapoor, Associate in our Medical Negligence team, has been working on behalf of his family, with David Story barrister at Hailsham Chambers representing during the inquest.
Shrdha said:
“This has been a lengthy and complex inquest and an incredibly challenging experience for Mohammed’s family, who have remained resilient throughout. I commend their courage in sharing and revisiting some of Mohammed’s darkest moments to help the Jury understand more of what Mohammed was experiencing and reporting to his loved ones from the Prison.
“This inquest has explored but not necessarily provided the family with all the answers they had hoped for, including whether doctors involved in Mohammed’s care truly ever got to the bottom of the reasons why he refused medication and treatment whilst in Prison.”
“The inquest has also highlighted concerns around the sharing of key information about Mohammed’s mental state with mental health professionals, which may have led to further exploration of his thinking processes and bizarre beliefs at the time of assessments with psychiatrists. The inquest has also highlighted real concerns about record keeping at HMP Norwich and the retrospective production of documents relevant to someone’s risk of suicide and self harm. Whilst it is extremely concerning to the learn of this during the inquest, the family will take some comfort in knowing that the Coroner will be writing a PFD report to the Prison Governor. This will also be reported to various bodies including HM Inspectorate of Prisons, HM Prison & Probation service, the Prison & Probation Ombudsman, the police and Independent Advisory Panel on Deaths in Custody.”
“Whilst I know this inquest and conclusion does little to comfort Mohammed’s family, I hope they are able to find some closure and remember Mohammed in happier times.”