A 21-year-old man died due to neglect, after he was not given treatment for HIV while he was a prisoner at Her Majesty’s Prison (HMP) Chelmsford, an inquest has determined. HIV is a “treatable” condition with the right care and no longer impacts the lifespan of suffers.
However, Thokozani Shiri, known as Thoko, died in April 2019 after pleading with prison staff to get him to hospital and after months of not receiving any medication for his condition. Thoko had been diagnosed with HIV in Zimbabwe in 2013 when he was a teenager before moving to the UK.
He spent two terms inside HMP Chelmsford the first between November and March 2018 where he received no medication or treatment for his condition until after his release.
He was then imprisoned again in March 2019 after stabbing a teenager during an altercation on a footpath in School Lane, Harlow, on October 8, 2018. Just two months later, on April 14, 2019, Thoko died.
An inquest into his death, before Her Majesty’s Assistant Coroner Michelle Brown, was held at Essex Coroners Court and concluded on June 8. The inquest heard that prison healthcare failed for months to provide anti-retroviral medication during those two periods of imprisonment that Shiri died from an HIV-related infection.
His treating consultant in the community gave evidence to the inquest saying that “Thoko was a young man”, that his HIV was “very treatable” and that his death “shouldn’t have happened”.
The jury was told that with his health deteriorating, on April 7, 2019, Thoko told a prison officer “I can’t breathe… I need to go to hospital”, but that an ambulance was not called until five days later.
A week after first making that request Thoko died at Broomfield Hospital. He was deemed vulnerable, having been treated for HIV before being imprisoned, and this was exacerbated by his dependency upon prison healthcare to provide him with life-saving medication.
In his first spell in prison, he received no medication for his HIV while in his second he only began to receive treatment in March 2019, just 19 days before his death. The prison healthcare provider, Essex Partnership University Trust (EPUT), said it had been aware during both imprisonments that Shiri had HIV.
When reaching their conclusions, the jury found that five separate failings had probably caused Thoko’s death. The failures identified by the jury included a failure to provide anti-retroviral medication to Thoko during both periods of imprisonment, a failure to refer him to an HIV clinic during both periods of imprisonment, and other systemic failings.
Thokozani Shiri died in hospital on April 14, 2019
Thokozani Shiri died in hospital on April 14, 2019 (Image: Essex Police)
The jury also concluded that each of those five areas of failure amounted to neglect, with the jury identifying a gross failure to provide basic medical attention to Thoko, who was in a dependent position, and that this failure had caused his death.
The prison officer who Thoko pleaded with to go to hospital has not been identified, and despite his family asking for the prison to provide and keep hold of the CCTV footage of the incident, the tape was overwritten and was therefore unavailable to be used in evidence at the inquest.
Coroner Brown was so concerned over this, and the fact that a senior prison governor appeared not to understand the medical emergency policy during his evidence to the inquest, that a formal report on the prevention of future deaths addressing this point will be sent to the Secretary of State for Justice.
Prison governors admitted at the inquest hearings that a “Code Blue” (medical emergency) alert should have been triggered and an ambulance should have been called on April 7 and not five days later.
The inquest also heard that when Thoko’s mother Beauty Shiri’s arrived at the hospital on April 13, arrangements had not been put in place quick enough to allow her to see her son before his condition deteriorated. Thoko had already been put into an induced coma when his mother was finally able to see him, from which he tragically never regain consciousness before his death
The inquest heard that despite being comatose the prison continued to restrain him unnecessarily with handcuffs. When his mother was finally allowed to see him, he was chained to the bed and barely recognisable to her. She stayed at his side until he died 12 hours later.
The Prison and Probation Ombudsman concluded in a damning report that “this was a case in which a young man died a preventable death as a result of what I can only describe as neglect by healthcare staff, and whose mother was then treated with gross insensitivity by prison staff”.
In a statement, the Shiri family said: “Thoko was just like any young man– he loved life, his friends and family. He was exploring what the world had to offer him, but he ended up on the wrong side of the law, culminating in a short-term custodial sentence. As a family, we had great hopes that this would allow him to reflect and look to a brighter future.
“This was not to be, as a short-term prison sentence turned into a death sentence. Thoko was denied very basic care that would have enabled him to live his life despite his long-term condition. We are saddened as we know that people with his condition do not have a reduced life expectancy and that, with basic management, his condition was not fatal.”
Leigh Day solicitor Maya Grantham, who represents Beauty Shiri, said: “Thoko was a young man, who was dependent on EPUT to provide basic medical care that would have saved his life. However, despite knowing Thoko had HIV, that basic medical care was not provided by EPUT to Thoko during two separate periods of imprisonment.
“The circumstances of Thoko’s preventable death must never be repeated, and it is hoped that this inquest investigation has shone a light onto those circumstances to ensure that will be the case.”
Paul Scott, chief executive officer for EPUT, said: “Our thoughts and condolences remain with Mr Shiri’s loved ones at this difficult time and we offer our sincere apologies that he didn’t receive the level of care expected.
“We no longer offer a prison service but are committed to learning lessons from this case and embedding them across our organisation to ensure that we provide the best possible care for all our patients.”
The trust ceased to provide its prison service in March 2019 following ‘a strategic review of its operations’.