Azroy Dawes-Clarke (3)
29 Jul 2025 · Coroner Ian Brownhill · Kent and Medway
This report repeats 5 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. ligature from bedding material
“Despite being in a safer cell, dressed in an anti-ligature gown, Mr [name redacted] was able to make a ligature from the bedding material in his cell. The material from which the mattress and pillow cover are made, permit strips to be ripped from them.”
2. inconsistent ACCT process training
“Officers involved in Mr [name redacted] ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork. Capacity to provide training to frontline officers and other civilian staff within the prison appeared to be limited.”
3. inadequate first aid training
“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support. During the course of the inquest, evidence was heard that whilst all uniformed prison officers would have regular training in respect of control and restraint, not all had recent (if any) training in first aid or basic life support. Some of the officers who gave evidence were unclear as to the correct response to a cardio respiratory arrest during physical restraint.”
4. misapplication of Mental Capacity Act
“Whilst the use of force paperwork completed following Mr [name redacted] physical restraint made mention of the Mental Capacity Act 2005, none of the officers (including the individual who completed the paperwork) appeared to have any basic understanding of the circumstances when the Mental Capacity Act may apply in a custodial setting. Equally, many were unclear as to what their role would be in conveying a prisoner who lacked the capacity to consent to their conveyance to hospital in a medical emergency. Answers in respect of handcuffing prisoners for the purpose of conveying them to hospital in a medical emergency varied. Answers in respect of the legal framework which applied when prison officers are involved in care and treatment of a prisoner (the particular issue in the present case being the conveyance to hospital and the decision to dress him) were inconsistent or incomplete.”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“Action is required to ensure that Prison Officers and Staff with direct access to prisoners have basic first aid training, CPR training and familiarisation with the use of a defibrillator.”
This report
“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support.”
Identical hazardConfidence 0.94 · high
Earlier report
“Training regarding the ACCT process. In previous prison deaths and in response to previous PPO reports, promises have been made about training having been provided to staff yet the same mistakes are being repeated.”
This report
“Officers involved in Mr [name redacted] ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork.”
Closely relatedConfidence 0.90 · high
Earlier report
“absence of clarity in the first aid training to prison officers on the use of rescue breaths during resuscitation attempts”
This report
“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support.”
Identical hazardConfidence 0.90 · high
Earlier report
“3. Training of staff in the ACCT process. 4. Prisoners being kept in their cells for up to 23 hours a day, with a negative effect on their mental health.”
This report
“(2) Officers involved in Mr [name redacted] ACCT process, described different experiences, familiarity and training in respect of the ACCT process. Some described finding new ACCT paperwork as difficult, others were unclear as to what matters should be recorded within the ACCT paperwork. Capacity to provide training to frontline officers and other civilian staff within the prison appeared to be limited.”
Identical hazardConfidence 0.90 · high
Earlier report
“Evidence was heard that the majority of those prison officers who had commenced in their roles prior to 2018 had no first aid/basic life-saving skills and no ability/training in undertaking cardiopulmonary resuscitation ('CPR').”
This report
“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support. During the course of the inquest, evidence was heard that whilst all uniformed prison officers would have regular training in respect of control and restraint, not all had recent (if any) training in first aid or basic life support.”
Identical hazardConfidence 0.90 · high
This report
“Officers who were present during Mr [name redacted] cardio-respiratory arrest had different training with regard to first aid and basic life support.”
Later report
“The court heard evidence that the first two officers on the scene failed to provide any form of basic life support despite having received training on how to do so.”
Responses
2025-0391-Response-from-HM-Prison-and-Probation-Service.pdf ↗· His Majesty's Prison and Probation Service
Stated action · end of 2026
“HMPPS are currently undertaking a cell design review which is looking at all aspects of cell design, including furniture and fittings, to ensure it takes account of developments in how prisoners are accommodated and improvements in what is currently available on the market. As part of this review, we will explore the possibility of using different materials which meet the stringent fire safety requirements and can also function as anti-ligature for bedding. The review is expected to conclude at”