Mohammed Azizi

Independent review           

Mr Azizi - HMP Norwich 

Bedfordshire, Cambridgeshire & Norfolk Group 

May 2024 

 – Regional Safety Lead  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Independent review – Mr Azizi HMP Norwich 

May 2024 

Overview   

On 24 September 2021, Mr Mohammed Azizi was sentenced to five years imprisonment 
for arson. Mr Azizi had Crohn’s disease and before he arrived at Norwich, he was 
admitted to hospital for treatment of a life-threatening inflammation of the stomach and a 
suspected bowel obstruction. Whilst in hospital Mr Azizi continuously refused to take 
medication for his conditions and he was also assessed by the mental health team who 
deemed that he had capacity to make decisions. 

On 11 August 2022, he was moved to HMP Norwich. Throughout his time at Norwich, Mr 
Azizi continued to refuse all medical treatment and despite attempts from staff to 
encourage Mr Azizi, he continued to eat only a limited amount and frequently refused 
blood tests and clinical observations. Mr Azizi was admitted to outside hospital on 
numerous occasions during his time in Norwich but continued to refuse treatment even 
when he was very unwell. 

Mr Azizi’s condition continued to deteriorate, and on 15 May, he died in hospital.  

The subsequent PPO report found that the care Mr Azizi received whilst at Norwich was 
of a very good standard and was equivalent to that which he could have expected to 
receive in the community. They found that the healthcare team at Norwich cared for Mr 
Azizi with compassion and dignity in difficult circumstances.  

The PPO report made no recommendations. 

Coroners court – inquest 

Samantha Goward, Area Coroner for the coroner area of Norfolk commenced an 
investigation and inquest on 23 May 2023.  

At the end of the inquest on 25 April 2024 the medical cause of death was:  

•  Cardiac Atrophy and Failure  
•  Malnutrition, Crohn’s Disease and Self-Neglect  
•  Pulmonary Thromboembolism and Infarction  

The conclusion of the inquest was: Mr Azizi died of cardiac atrophy and failure with 
contributing factors of malnutrition, Crohn's disease, self-neglect and a pulmonary 
thromboembolism and infarction due to his continued refusal of treatments. 

The inquest found that Mr Azizi was placed under an ACCT on two occasions while at 
HMP Norwich. The second of these was opened on 26.03.23. However, during the 
course of the inquest, one of the Officers called to give evidence, indicated that she was 
not familiar with the ACCT document, and that there was in fact a second ACCT 
document of the same date, with the same reference number, that had been opened by 
her.  

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 Independent review – Mr Azizi HMP Norwich 

May 2024 

The Officer’s evidence was that, although the document originally disclosed bore what 
appeared to be her signature, this had not in fact been signed by her. She reported that 
when she was asked to prepare a witness statement for the purpose of the inquest in 
December 2023, she was provided with both copies of the document, and raised a 
concern that one was not completed or signed by her.  

She also gave evidence that she thought the document not signed by her may have 
been a photocopy of her signature.  

Upon inspecting the two original documents, neither was a photocopy and both appear to 
have been completed in pen. The member of staff who closed the ACCT then also gave 
evidence and he also advised that the document originally disclosed to the Court (and 
PPO) which appeared to bear his written and electronic signature, had not been signed 
by him. 

As a result of the investigation it revealed matters giving rise to concern. The coroner 
recorded a risk that future deaths could occur unless action is taken. Subsequently she 
issued a Regulation 28: REPORT TO PREVENT FUTURE DEATHS to HMP Norwich. 

Reg 28 Report - After 
Inquest AZIZI M A 150

Independent review 

Following the receipt of the regulation 28 report to prevent future deaths as per attached 
the Prison Group Director requested an independent review of actions taken and 
information available.  

This independent review was completed by the regional group safety specialist. 

As part of an independent review, we assessed the following documents:  

•  Regulation 28 
•  PPO report 
•  ACCT documentation 
•  Local management enquiry 
•  Statement of actions taken by Security Governor 
•  Local data loss logs 

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 Independent review – Mr Azizi HMP Norwich 

May 2024 

Responses to matters of concern 

The MATTERS OF CONCERN raised in regulation 28 are as follows: 

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.  

•  Our inquiry has concluded that this is the case, two ACCT documents were open at the 
same  time.  The  second  document  was  opened  in  good  faith  by  a  member  of  staff  who 
genuinely believed that the original document had been misplaced. However, the process 
for opening a duplicate document wasn’t effectively followed which did cause confusion.  

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  have  been  unable  to  provide  an  explanation  as  to  when,  how  or  by  whom,  the 
second document was created.  

•  Our inquiry has concluded that a member of staff did complete a duplicate ACCT document. 
This was not a photocopy version of the original ACCT; it was a duplicate version which 
the member of staff created from the best of her knowledge in the genuine belief that the 
original document had been mislaid. Our enquiries have also raised concerns into the depth 
of investigation that took place at the time of the incident and accept this should have been 
thoroughly looked at.   

We also had evidence from another Officer who said that as part of a Quality Assurance 
review, she was asked to add notes to an ACCT document after it had been closed, she 
thought roughly six weeks later (that was to the document that the witnesses said had not 
been signed by them). 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. 

•  As part of our inquiry we are unable to substantiate this claim. Although the member of staff 
was spoken to be a senior leader prior to the inquest there is no clear evidence that the 
conversation  directed  the  member  of  staff  to  add  notes  to  the  document.  However  as  a 
result  all  future  support  and  advice  for  staff  will  be  provided  by  the  SPOC  and  regional 
safety specialist only. 

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 Independent review – Mr Azizi HMP Norwich 

May 2024 

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. 

•  Our inquiry found that systems have now changed specifically regarding ACCT 

documentation to ensure that all concerns are identified and addressed at the earliest 
opportunity. Regional assurance support visits have also increased in conjunction with the 
local quality assurance system. As a result the safety team ensure that targeted actions 
are taken which are evidenced through relevant meetings and escalated where 
necessary. Operational staff briefings are more targeted to ensure staff are aware of their 
responsibilities and there is now published guidance for to support delivery. 

There are also concerns about disclosure of documents and how it came to be that both 
the Court and the PPO received just one of 2 documents that existed for the same date, 
and  that  neither  was  advised  of  the  concerns  previously  raised  Regulation  28  –  After 
Inquest  Document  Template  Updated  30/07/2021  regarding  the  document  that  was 
disclosed. Had the Officer in question not been called to give evidence in Court and her 
statement  simply  read  into  evidence,  the  Court  would  never  have  been  aware  of  the 
existence of the second ACCT document nor the issues surrounding it and nor would the 
PPO, which is of significant concern. The Court was not provided with evidence to explain 
how this occurred, who disclosed the documents and why they only disclosed one, or how 
only one came to have been scanned on to the electronic system that was used to then 
provide disclosure. While it may not have been causative in Mr Azizi’s case, the importance 
of a document such as an ACCT may well have greater significance in other situations.  

•  Our inquiry found that there were concerns around documentation not being supplied to 
the PPO to support the completion of the independent review of death in custody. A review 
of previous deaths in custody has evidenced that this appears to be an isolated case and 
documentation  was  supplied  as  soon  as  located  which  unfortunately  was  post  the  PPO 
investigation. This isn’t acceptable, all sites will be written to by the PGD to remind them of 
their responsibilities in supplying documentation when requested without delay. 

It is unclear whether the two versions were in use at the same time. Both have sections 
completed  by  different  Officers,  which  may  suggest  they  were,  although  none  of  the 
witnesses who gave evidence were aware of this or had ever been aware of this in their 
career. However, the existence of 2 documents, were it to happen, would also give rise to 
concern as no single document would contain a full and complete picture. 

•  As part of our inquiry, we can conclusively state there were two ACCT documents that ran 
simultaneously from the evidence seen. Therefore, following the interviews with staff as 
part of the management enquiry where no staff report that this was the case we can only 
conclude that the original document was missing and only located later following the PPO 
investigation.  

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 Independent review – Mr Azizi HMP Norwich 

May 2024 

If  the  Coroner  and  PPO  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 and 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. 

•  A senior SPOC will always be appointed to any future cases who will have full responsibility 
for ensuring full access/disclosure of any documents requested. All sites will be written to 
by the prison group director to remind them of the importance of allowing PPO colleagues 
unfettered access to documentation. 

Conclusions  

The care Mr Azizi received whilst at Norwich was of a very good standard and was 
equivalent to that which he could have expected to receive in the community. 

Our enquiry found that there were in fact two ACCT documents opened for Mr Azizi. It is 
clear that the rationale behind this was that staff genuinely believed that the original 
document had been misplaced.  

The process for opening a duplicate ACCT was poor and did not clearly evidence why 
this had taken place.  

The original ACCT document was not reported as a data loss, there is concerns that this 
potentially this could happen again without necessary action.  

The presence of two ACCT documents in no way contributed to Mr Azizi’s death. 

The disclosure of documentation and process to the PPO was not acceptable.  

Recommendations  

The member of staff involved to receive advice and guidance by the site and from the 
group safety specialist. 

All future support and advice for staff during an inquest will be provided by the SPOC 
and regional safety specialist only. 

There is a need locally for all management grades to be supported and reminded of the 
process of reporting and requirements in the identification of data losses to ensure 
compliance with policy.  

All sites in region will be written to by the PGD to remind them of their responsibilities in 
supplying documentation when requested without delay. 

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