On 6 July 2009, an inquest jury recorded a highly critical verdict of neglect in the death of Godfrey Moyo in HMP Belmarsh.
Twenty-five-year-old Godfrey Moyo, a Zimbabwean, died while on remand at the Category A Belmarsh prison on 3 January 2005 in the early hours of the morning after suffering an epileptic fit. Godfrey’s family had to endure a four year wait for the inquest to discover what happened on that night. To add to the agony experienced by the family, Godfrey’s mother, Kessie, almost missed the inquest after she was initially refused a visa to come back to the UK. (Read an IRR News story: ‘The ordeal of Kessie Moyo’.) Godfrey does not seem to have been a difficult prisoner. He was variously described during the inquest by officials as a ‘smashing bloke … [who] always smiled and always said “hello”‘ and a ‘gentle, emotional young man’ by someone who worked in the chapel.
The eleven day inquest took place at Southwark coroner’s court in front of a jury and before the coroner Andrew Walker. The family of Godfrey Moyo was assisted by INQUEST and represented by Daniel Machover (Hickman & Rose) and Leslie Thomas (Garden Court Chambers). The Prison Service also had its own legal representation, as did the Prison Officers’ Association, a nurse and a doctor.
The inquest jury was told how Godfrey Moyo, a known epileptic, was restrained face down by up to seven prison officers for at least thirty minutes and then carried to a cell in the healthcare unit where he was injected with a sedative and left, with his face to one side, on his knees leant against a bed for approximately an hour. When officers returned to the cell to move him on to a bed he was found not to be breathing. Resuscitation was started and an ambulance called. Godfrey was pronounced dead at 5.40am at the Queen Elizabeth Hospital, Woolwich, nearly three hours after officers had first entered his cell as he suffered an epileptic fit. The evidence at the inquest raised numerous concerns about the care and treatment that Godfrey received.
What happened?
On 3 January 2005, at about 2.50am, an alarm was sounded from a cell in House Block 3 at Belmarsh. The prison officer (TS) who went to investigate, found a prisoner in the three-man cell ‘looking terrified’ gesturing to Godfrey Moyo who was on the floor suffering from an epileptic fit, ‘rocking backwards and forwards very violently’. The officer aware that Godfrey suffered from epilepsy (as on a previous occasion he had punched an officer during a fit and later begged to apologise) immediately called the health care centre (HCC) and told the officer that Godfrey would need medical attention and then contacted the orderly office to make sure the officer in charge of the prison at night, (the night orderly officer – HB) was aware of the situation. This officer decided to ask for the dog handlers.
Why the door to Godfrey’s cell was not opened and assistance given to him immediately is open to question. And why dogs were needed is also puzzling, but appears to be part of a rigid policy across Category A prisons when opening any cell at night. TS then returned to the cell where Godfrey remained on the floor, suffering from seizures. Her instructions to the prisoner who sounded the alarm – to place a pillow and blankets around Godfrey – had not been followed as he did not speak English. Three other prison officers arrived (HB, PL and CR). and all watched what was happening to Godfrey from outside the cell, while waiting for a dog handler and dog to arrive. As TS explained to the others what had happened, one of the officers saw that Godfrey, in a seizure, had struck out at one of his cell-mates injuring him. The three officers decided to enter the cell and began to restrain Godfrey. During the restraint inside, one was punched and bitten on the elbow and another was punched, while the third hurt herself while bringing Godfrey under control. The officers managed to get Godfrey outside the cell and other officers joined in the restraint of Godfrey who was placed face-down in a prone position and handcuffed. A nurse (WM) was also present during most of the restraint with the responsibility of checking on the health of Godfrey. She also tended to the injured cell mate.
The first offices, TS, who had been calming other prisoners down, heard Godfrey, ‘not screaming but a chilling sort of roar’, which she had ‘never heard before or since’. At the cell she found Godfrey, handcuffed, face down outside ‘sleeping to all intents and purposes’. However, TS said that Godfrey continued to suffer more seizures which were described as ‘juddering’, with each lasting a few minutes and then Godfrey ‘seemed asleep’. There were now at least four officers present and a nurse. Godfrey was restrained by up to four officers, one on his legs, on on each arm and another controlling his head. Godfrey was then lifted and taken to the healthcare unit by five officers in a U-shape and accompanied by another nurse, MS.
A number of prison officers gave evidence that during the short journey to the healthcare unit Godfrey continued to struggle and therefore the restraint continued. When shown CCTV footage of (part of) the short journey they were unable to point out the times at which the seemingly unconscious Godfrey was struggling with them. Officers were so exhausted by the continued restraint that they had to rest twice on this short journey.
Once at the healthcare unit Godfrey was taken to the intensive care cell (ICC) where he was placed on his knees against a bed and given a sedative (lorazepam) injection authorised by a doctor over the phone. After the injection was administered and the handcuffs removed all the prison officers and nurse exited the room. Godfrey was then observed from outside the room, through the hatch in the door.
Nearly an hour after he was placed in the room, officers re-entered to make Godfrey ‘more comfortable’ and place him on the bed and it was discovered he was not breathing and resuscitation was started (while he was still on the bed).
The evidence
The inquest heard from three pathologists, two of whom conducted post mortems on Godfrey and gave differing causes of death. Dr Jerreat, the pathologist appointed by the coroner, found that Godfrey had died from asphyxia following an epileptic fit. He also found neck injuries, petechial haemorrhages, (together indicating compression of Godfrey’s neck) and left ventricular failure. The second pathologist, Dr Milroy, found the cause of death to be undetermined and that there were complex and competing factors in the death including the control and restraint, epilepsy and asphyxia. He was in no doubt that neck compression had occurred. Although there were competing factors in Godfrey’s death he found that epilepsy in association with positional asphyxia had caused the death.
Another pathologist, Dr Sheppard, examined the records and reports of others, and found that positional asphyxia, restraint and epilepsy had caused Godfrey’s death. An expert toxicologist, Mr Slaugher, found no lorazepam (sedative given in the ICC) in Godfrey’s body which would suggest that Godfrey died before the injection or it was never administered or he died within thirty minutes of the injection, as otherwise the drug would have entered his blood stream.
Professor Gournay, a professor of psychiatric nursing and a chartered psychologist with forty-two years in the field, gave evidence to the inquest about epilepsy and general nursing practice. He said that there should have been written records about Godfrey’s vital signs (temperature, pulse, respiration and colour), the medical staff should have recorded the frequency, nature and type of seizure that Godfrey suffered. And when monitoring a patient with epilepsy that ‘breathing and colour’ were most important. It was not reliable to take a pulse at the wrists if a patient was handcuffed and if a patient was unconscious the only position that they should be in was the recovery position and that it was a ‘gross failure’ to ensure that this position was not adopted. He also said that breathing and pulse could not be monitored through CCTV, as a patient’s face and eyes needed to be observed.
The inquest also heard evidence from the two nurses and the prison officers who were at the scene of the restraint and in the HCC. The prison officers denied using any excessive force while also referring to Godfrey as struggling during the restraint and attempting to ‘kick out’, any concerns about his health were disregarded as restraining the ‘violent’ prisoner became the most important course of action. The nurses’ basic training seems to have been forgotten as they seemed too frightened of Godfrey to provide him with the most basic of care – resorting to drugs to calm him down rather than treating the epilepsy. (Download and read the evidence of prison officers and medical staff – word doc 115kb).
Jury verdict
The jury recorded a unanimous and highly critical narrative verdict that Godfrey died from ‘Positional asphyxia, left ventricular failure following restraint and epileptic fits’. In their narrative they found that ‘Mr Godfrey Moyo suffered an epileptic fit in his cell. Prison officers were alerted and together with a nurse were dispatched to the cell. Upon regaining consciousness, Mr Moyo experienced post ictal behavioural disturbance and attacked a cellmate. Prison officers entered the cell to bring Mr Moyo under control. A vigourous struggle ensued between Mr Moyo and five prison officers in which 3 officers sustained injuries. Prison officers brought Mr Moyo to the floor on the landing outside the cell. Full control was achieved immediately. Mr Moyo was then restrained in the face down prone position for approximately 30 minutes. During this time Mr Moyo suffered at least 2 further fits, followed by periods of unconsciousness in which his breathing was restricted as a result of his position. Mr Moyo began to suffer from the effects of positional asphyxia. The first nurse on the scene failed to adequately monitor Mr Moyo’s condition during the restraint, which contributed to his death by neglect. The prison officers also failed to recognise the signs of distress being shown by Mr Moyo during the restraint, as highlighted by their control and restraint training. At no time during the restraint by any persons present was an attempt made to move Mr Moyo off his front as per the control and restraint guidelines or place him in the recovery position during periods of unconsciousness. Upon arrival of the second nurse, Mr Moyo was lifted from the prone position and carried to the health care centre. Throughout the move Mr Moyo was unconscious. Upon arrival to the health care centre at approximately 3.30am Mr Moyo was placed in the Intensive Care Cell in a kneeling position against the cell bed with his upper chest and head resting on the mattress. His head was resting on the mattress while in a kneeling position Mr Moyo remained under restraint. A doctor prescribed a 2mg intra muscular dosage of Lorazepam by telephone. The second nurse administered the drug to Mr Moyo and exited the cell followed by the prison officers. Mr Moyo died in the intensive care cell between 3.30 to 3.50am. The second nurse failed to adequately monitor Mr Moyo’s condition while he was in the intensive care cell, which directly contributed to Mr Moyo’s death by neglect. The first nurse raised concerns on her ability to monitor Mr Moyo’s condition while he was in the ICS to the second nurse. However these concerns were not acted on. In addition insufficient communication between the two nurses prevented the seriousness of Mr Moyo’s condition being properly recognised, which meant that an ambulance was not called until too late, approximately an hour after Mr Moyo was placed in the intensive care cell.’
Implications
The coroner, Andrew Walker, commented that ‘there was a complete lack of understanding of epilepsy by all who came into contact with Godfrey. The system was fundamentally flawed and steps must be taken to prevent future deaths.’ Walker is to submit a Rule 43 report to the Ministry of Justice. Such a report by the coroner is made to a person or an organisation where action needs to be taken to prevent future deaths.
The inquest was characterised by conflicting and changing evidence from medical staff and prison officers at Belmarsh. A constant refrain that was heard throughout the inquest from prison officers was that of ‘I’m not medically trained’ (despite having received training in the illegality of neck-holds and the dangers of positional asphyxia) and the nurses sought to blame one another. The care and attention which the jury and coroner afforded Godfrey, in his death, was more than was afforded to him in life by those who should have treated him as a patient rather than a prisoner.
After the verdict, Daniel Machover told IRR News: ‘The death of Godfrey Moyo through neglect could have been avoided if basic care of ill prisoners had been the uppermost concern of the staff who came into contact with him on 3 January 2005. The Prison Service and prison officers displayed immense arrogance during the inquest, when describing the situation as somehow being so unique that Godfrey Moyo’s death was unavoidable and nothing would be done differently in similar circumstances in future. The family seeks accountability in respect of those criticised by the jury, as without such accountability it seems unlikely that real changes will take place to protect ill prisoners, particularly those suffering from epilepsy, from untimely deaths at the hands of prison officers.’
Related links
Download and read the evidence of prison officers and medical staff (word doc 115kb)
IRR News story: ‘Police launch investigation into Black man’s death at Belmarsh’
IRR News story: ‘The ordeal of Kessie Moyo’