A coroner has demanded answers after two Norwich Prison officers told an inquest into an inmate's death that a document about his care with their signatures on had not been signed by them.
Area coroner Samantha Goward said her concerns about evidence presented at an inquest into the death of 32-year-old prisoner Mohammed Azizi were "so serious" she wants action to prevent potential future deaths.
How did Mohammed Azizi die?
At the end of a seven-day inquest, during which Mr Azizi's family raised concerns over his treatment, a jury concluded he died of cardiac atrophy as a result of malnutrition, Crohn’s disease and self-neglect, with pulmonary thromboembolism and infarction.
The inquest heard Mr Azizi, originally from Essex, had been diagnosed with Crohn's disease in 2012 and deep vein thrombosis in 2022.
He had been moved to Norwich Prison in August 2022 to have access to 24-hour care, but had been regularly admitted to hospital.
The jury said he had regularly refused food and treatment and had been advised by medical professionals that doing so could result in his death.
Mr Azizi, who had been jailed for arson, was admitted to the Norfolk and Norwich University Hospital on April 24 last year. He died there on May 15.
What was the issue with the evidence?
During the inquest at Norfolk Coroner's Court, two officers at Norwich Prison said a document about Mr Azizi's care - submitted by the prison service as evidence - had not been signed by them, even though it appeared to contain their signatures.
The inquest also heard that another officer had been asked to add notes to the Assessment, Care in Custody and Teamwork (ACCT) plan - produced for prisoners identified as being at risk of suicide or self-harm - after it was supposed to have been completed.
Mrs Goward said, in the case of Mr Azizi, suicide and self-harm had not, ultimately, been factors in his death, but that she was concerned about what had occurred with those documents.
She said she will write a Prevention of Future Deaths report, which will be sent to the prison service, which will have 56 days to respond.
What does the prison service say?
Barristers for the prison service had tried to convince Mrs Goward that there was no need for a Prevention of Future Deaths report.
The coroner heard an investigation into the issue over documents took place last December.
Mrs Goward heard the prison governor had not taken it further, believing it was down to a "misunderstanding" involving photocopied documents.
Barrister Jennie Oborne, on behalf of the Ministry of Justice (MOJ), told the coroner: “Since this issue came to light, the matter has been raised with the senior leadership team within the prison and with the wider MOJ outside the prison as well.
“The current plan is that the investigation is reopened within the prison and this is reinvestigated.
“This matter is being addressed at the highest level and is being taken extremely seriously by the prison.”
She said this matter was a “one-off” occurrence and not a “systemic problem”.
What did the coroner say?
Mrs Goward said: "We have heard evidence from two witnesses who say the signatures in ACCT documents which appeared to be theirs were not made by them."
She said, while the prison service had given assurances over the issue, she had not had an explanation as to precisely what had happened.
She said, in the case of Mr Azizi, the details outlined in the plan had not been factors in his death, but that such plans could be "significant" in other situations.
Mrs Goward said it appeared two different ACCT documents might have been produced, potentially completed by different officers, but questioned why only one had been provided to the court.
She said: "If hampered by the lack of full disclosure, there is a risk the full picture is not received and any findings, conclusions and lessons might not address full concerns.
"I will issue a report expressing my concern regarding these issues.
"While I am advised this will be looked at as a result of this, I consider it so serious that a formal report is required to ensure my concerns are raised at the appropriate levels and responded to."
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