A Norfolk prison has come under fire for providing the courts with documents signed by prison officers who revealed they did not sign them. 

The two officers from Norwich Prison told an inquest into an inmate's death that a document about his care with their signatures on had in fact not been signed by them. 

So serious were the concerns of area coroner Samantha Goward, she has filed a Prevention of Future Deaths (PFD) report to prompt preventative action. 

The issue was raised after evidence was presented at last month’s inquest into the death of 32-year-old prisoner Mohammed Azizi

At the end of a seven-day inquest held at Norfolk Coroner’s Court, a jury concluded he died of cardiac atrophy as a result of malnutrition, Crohn’s disease and self-neglect, with pulmonary thromboembolism and infarction. 

Mr Azizi, originally from Essex, had been diagnosed with Crohn's disease in 2012 and deep vein thrombosis in 2022. 

Eastern Daily Press: Mohammed Azizi

He had been moved to Norwich Prison in August 2022 to have access to 24-hour care but had been regularly admitted to hospital. 

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. 

During the inquest, two officers from Norwich Prison said a document submitted by the prison service as evidence about Mr Azizi's care 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 that while in the case of Mr Azizi, suicide and self-harm had not been factors in his death, she was concerned about what had occurred with those documents. 

She has now submitted her report to the governor of HMP Norwich, as well as the Ministry of Justice, HM Inspectorate of Prisons, HMP and Probation Service and the Independent Advisory Panel on Deaths in Custody. 

In her report, she 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. 
“The evidence was that any enquiries into the concern raised by the officer in December 2023 were limited, as it was felt that it was simply a misunderstanding and some documents had been photocopied.  

“We had the original documents in court and both appear to have been handwritten in pen and one is not a photocopy of anything else. The prison has been unable to provide an explanation as to when, how or by who, the second document was created.” 

Eastern Daily Press: HMP Norwich

Of her concerns about notes being added to the ACCT document after it had been closed, she added: “This raises concerns that an officer was asked to recreate sections of a document and effectively back date them, without making it clear that this is a retrospective entry and for what reason. 

“The court was advised by counsel for the prison that this system has changed, but there was no evidence from the prison to support this and confirm why this could not happen again.” 

Finally, she addressed the issue of extra documents being withheld until court was under way. 

“If the coroner and Prisons and Probation Ombudsman investigations are hampered by a lack of full disclosure and potentially inaccurate or recreated documents, there is a risk that a full picture is not received. 

“Any findings, conclusions and lessons learnt from those enquiries may not fully address all concerns and risks, and that could lead to the same things happening again and therefore a risk of future deaths.” 

HMP Norwich will have 56 days to respond.