Inquest jury find multiple failings and neglect in death of HIV positive prisoner

Adam Wagner acted for the family of Thoko Shiri, 21, who died on 14 April 2019. He was instructed by Maya Grantham of Leigh Day & Co. 

The inquest into Thoko’s death, before Her Majesty’s Assistant Coroner Michelle Brown, was held at Essex Coroners Court and concluded on Wednesday 8 June, 2022.

Thoko, of Essex, was HIV positive but the prison healthcare failed for months to provide anti-retroviral medication during two periods of imprisonment in 2017 and 2018. He sadly died on 14 April 2019 from an HIV-related infection. His treating consultant in the community gave evidence to the inquest that Thoko was “a young man. HIV is very treatable. It shouldn’t have happened”.

As his health deteriorated, Thoko told a prison officer “I can’t breathe… I need to go to hospital” but an ambulance was not called until five days later.

Thoko was a prisoner at HMP Chelmsford when he died at Broomfield Hospital on 14 April 2019. He was a young man in a vulnerable position, due to his long-standing diagnosis of HIV, for which he was receiving treatment prior to his imprisonment. His vulnerability was exacerbated by his dependency upon prison healthcare to provide him with life-saving medication.

Thoko was imprisoned at HMP Chelmsford from 13 November 2017 until 19 March 2018. However, he was not seen at an HIV clinic until 13 March 2018 and he did not receive any HIV medication before his release.

Thoko was again imprisoned at HMP Chelmsford from 10 October 2018 until his death on 14 April 2019. On that occasion, he did not attend an HIV clinic until 23 March 2019, and he did not receive HIV medication until 26 March 2019, some 19 days before his death.

The prison healthcare provider, Essex Partnership University Trust (EPUT), were aware that Thoko had HIV throughout both his periods at HMP Chelmsford.

Jury conclusion

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 antiretroviral medication to Thoko during both periods of imprisonment, a failure to refer Thoko to an HIV clinic during both periods of imprisonment, and other systemic failings. 

The jury also concluded that each of those five areas of failing amounted to neglect. This means that the jury identified a gross failure to provide basic medical attention to Thoko, who was in a dependent position, and that the failure had caused Thoko’s death.

Thoko became unwell on 7 April 2019. He told a prison officer “I can’t breathe… I need to go to hospital”. Despite that conversation being recorded, that prison officer has still not been identified by the Ministry of Justice. Shortly after Thoko’s death, the family requested that CCTV footage from 7 April be preserved. However, all CCTV footage of 7 April was overwritten and was unavailable to the inquest. 

The Coroner was so concerned that the prison officer in question had not been identified by the time of the inquest, over three years later, and the fact that a senior prison governor appeared not to understand the “Code Blue” 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” should have been triggered that day meaning an ambulance would have been called, but Thoko was not admitted to hospital until five days later on 12 April 2019.

The inquest heard how, upon Thoko’s mother Beauty Shiri’s arrival at the hospital on 13 April, arrangements were not put in place as quickly as they should have been to allow her to see her son before his condition deteriorated. Thoko was already in an induced coma, as he remained until his death, when his mother was finally able to see him. The inquest heard that, whilst in an induced coma, the prison restrained him unnecessarily with handcuffs.

When Thoko’s 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 is 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”.

Read the full press release on the Leigh Day website here.