A jury inquest into the death of a 21-year-old who died from a HIV-related infection following two periods of imprisonment has found that systemic failures in the provision of prison healthcare contributed to his demise. Thokozani (‘Thoko’) Shiri was a prisoner at HMP Chelmsford when he died at Broomfield Hospital on 14 April 2019. The jury at the inquest into his demise heard evidence which confirmed that he did not receive any HIV medication during his first period of imprisonment in 2018 and that during his second term in prison in 2019, he did not receive HIV medication until 26 March 2019, some 19 days before his death. As his health deteriorated, Thoko reportedly told a prison officer, ‘I can’t breathe… I need to go to hospital,’ but an ambulance was not called until five days later.
Essex Partnership University Trust (EPUT), the healthcare provider responsible for the delivery of medical services at HMP Chelmsford, were aware that Thoko had HIV throughout both his periods of imprisonment. The inquest found that five separate failings had played a part in 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; a gross failure to provide basic medical attention to Thoko, who was in a dependent position, had caused his death.
In a report issued following Thoko’s death, the Prison and Probation Ombudsman found 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.’ During the inquest, evidence emerged that arrangements were not put in place as quickly as they should have been to ensure that Beauty Shiri, Thoko’s mother, could see her son before his condition deteriorated. By the time Thoko’s mother was allowed to see her son, Thoko was already in an induced coma, which he remained in until his death. The inquest heard that, whilst in an induced coma, the prison restrained him unnecessarily with handcuffs.
‘Thoko was a young man, who was dependent on EPUT to provide basic medical care that would have saved his life,’ said Maya Grantham from the law firm Leigh Day, who represented Beauty Shiri during the inquest. ‘However, despite knowing Thoko had HIV, that basic medical care was not provided by EPUT to Thoko during two separate periods of imprisonment,’ added Grantham. ‘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.’
Thoko’s case has prompted renewed scrutiny of the quality of prison healthcare services across England and Wales. Selen Cavcav, a senior caseworker at the legal charity INQUEST, said: ‘This is a very disturbing case which raises serious issues around the failure to provide basic health care to a young black man. This is not the first neglect conclusion against this prison nor is it the first neglect conclusion involving EPUT whose actions are already a subject to an independent inquiry.’
‘It’s only through proper culture change and corporate accountability that further deaths can be prevented.’