Coroner warns of prison deaths if action not taken

A coroner has written to a prison governor warning "future deaths could occur" unless the site takes action on how it records inmates at risk of suicide and self-harm.

An inquest into the death of Mohammed Azizi, an inmate at HMP Norwich, found the signatures of two prison officers had been used on his care documents without their knowledge.

Mr Azizi died in hospital of malnutrition and self-neglect in May 2023, having previously complained that prison food had made his Crohn's disease symptoms worse.

The Ministry of Justice said it would consider the coroner's findings carefully and respond in due course.

The altered document relates to an "assessment, care in custody and teamwork" document (known as an ACCT) which records the care planning process for vulnerable prisoners.

In her prevention of future deaths report, the area coroner for Norfolk Samantha Goward said: "A document has been created, which two witnesses said under oath bears what appears to be their signatures, but both confirmed they did not in fact sign those documents.

"In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action."

HMP Norwich must reply to the coroner by 26 June, outlining what actions will be taken.

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