HMP Chelmsford prisoner who died of HIV was neglected by healthcare staff, jury rules at an inquest

He had been receiving treatment for HIV before going into prison.

Thokozani Shiri died in hospital on April 14th, 2019.

A 21-year-old man died due to neglect after he was not given treatment for HIV while he was a prisoner at HMP Chelmsford, an inquest has determined. HIV is a 'treatable' condition with the proper care and no longer affects the lifespan of sufferers.

However, Thokozani Shiri, known as Thoko, died in April 2019 after pleading with prison staff to get him to the hospital 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 imprisoned again in March 2019 after stabbing a teenager during an altercation on a footpath in School Lane, Harlow, on October 8th, 2018. Just two months later, on April 14th, 2019, Thoko died.

Before Her Majesty's Assistant Coroner Michelle Brown, an inquest into his death was held at Essex Coroners Court and concluded on June 8th. The inquest heard that prison healthcare failed for months to supply anti-retroviral medication during those two periods of imprisonment that Mr 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 "should not have happened".

The jury was told that with his health deteriorating, on April 7th, 2019, Thoko said to a prison officer, "I cannot breathe… I need to go to the hospital." However, an ambulance was not called until five days later.

A week after first making that request, Thoko died at Broomfield Hospital. He was considered vulnerable, having been treated for HIV before imprisonment, and his dependency worsened 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, said it had been aware during both imprisonments that Mr Shiri had HIV.

When reaching their conclusions, the jury found that five separate failings had caused Thoko's death. The failures the jury found included not supplying anti-retroviral medication to Thoko during both periods of imprisonment, not referring him to an HIV clinic during both periods of imprisonment, and other systemic failings.

The jury also concluded that each of those five areas of failure amounted to neglect. The jury found a gross failure to supply basic medical attention to Thoko, who was in a dependent position, and that this failure had caused his death.

The prison officer Thoko pleaded with to go to hospital has not been found. Despite his family asking for the prison to supply and keep hold of the CCTV footage of the incident, the tape was overwritten. It was, therefore, unavailable to be used in evidence at the inquest.

Coroner Brown was so concerned 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 would 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 7th and not five days later.

The inquest also heard that when Thoko's mother, Beauty Shiri's arrived at the hospital on April 13th, arrangements had not been put in place quickly 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 regained 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 twelve 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 explored what the world had to offer him but ended up on the wrong side of the law, culminating in a short-term custodial sentence. As a family, we hoped 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 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 stands for Beauty Shiri, said: "Thoko was a young man dependent on Essex Partnership University Trust to supply basic medical care that would have saved his life. However, despite knowing Thoko had HIV, that basic medical care was not provided by Essex Partnership University Trust 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 Essex Partnership University Trust, said: "Our thoughts and condolences stay with Mr Shiri’s loved ones at this rough time, and we offer our sincere apologies that he did not 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 we supply the best care for all our patients."

The trust ceased to supply its prison service in March 2019 following "a strategic review of its operations".