Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0388, written 29 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jul 2025 |
|---|---|
| Reference | 2025-0388 |
| Deceased | Azroy Dawes-Clarke |
| Coroner | Ian Brownhill |
| Coroner area | Kent and Medway |
| Category | State Custody related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Kent and Medway Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE Telephone: Email: Date: Case: 29 July 2025 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) The Secretary of State for Justice; (2) The Secretary of State for Health and Social Care. 1. CORONER I am Ian Brownhill, Assistant Coroner for Kent and Medway. 2. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3. INVESTIGATION and INQUEST On 26 November 2021 an investigation commenced into the death of Azroy DAWES-CLARKE. The investigation concluded at the end of the inquest on 11 July 2025. The jury returned a narrative conclusion which read: “From hearing all the evidence presented to us, we conclude that Azroy Dawes-Clarke died from a combination of factors beginning with the compression of the neck via self-inflicted ligaturing. This was followed by a disproportionate use of force by prison o(cid:431)icers during control and restraint which led to Mr Dawes-Clarke going limp. After restraint, there was insu(cid:431)icient action taken by prison sta(cid:431) and paramedics upon realising Mr Dawes-Clarke's cardiac and respiratory arrest. From the body-worn footage, it is evident that prison sta(cid:431) neglected to consider Mr Dawes-Clarke's head positioning and breathing throughout the restraint. The poor practice of applying handcu(cid:431)s while Mr Dawes-Clarke was in a kneeling position more than minimally increased the risk of positional asphyxia.” The medical cause of death was determined to be: 1a Hypoxic ischaemic brain injury due to cardio-respiratory arrest in close temporal proximity to a period of third party restraint shortly after apparent seizure like activity following compression of the neck by a ligature 1b 1c 1d II 4. CIRCUMSTANCES OF THE DEATH Azroy Dawes-Clarke died at Medway Maritime Hospital on 10 November 2021. The jury who heard the case, recorded that, “prior to the 10th November and on the day of Mr Dawes-Clarke's passing, there was a lack of communication between all parties involved with regards to Mr Dawes-Clarke's physical and mental health.” Mr Dawes-Clarke had ligatured in both the houseblock, and in the separation and care unit of HMP Elmley, prior to the date of his death. A decision was made to move Mr Dawes-Clarke to the inpatient department of HMP Elmley. Mr Dawes- Clarke was placed in a safer cell with no ligature points. He applied a ligature to his neck, self-strangulating. The jury recorded, “Mr Dawes-Clarke did not intend to end his own life when he used the ligature on the 10th November. Rather, ligaturing was a known coping mechanism of Mr Dawes- Clarke, which he would use in order to be listened to.” A member of healthcare sta(cid:431) saw him self-strangulating. O(cid:431)icers entered the cell and removed the ligature. A, “code blue” was called, which automatically caused an ambulance to be called to the prison. Prison healthcare sta(cid:431), including two general practitioners working within the prison at the time were able to attend the cell and stabilise Mr Dawes-Clarke. Paramedics attended the inpatient department and made the decision to convey Mr Dawes-Clarke to hospital. The prison healthcare sta(cid:431), including the general practitioners then left the area. The general practitioners provided a handover to the paramedics and left the prison it being the end of their shift and nobody asking them to stay. Mr Dawes-Clarke had been wearing an anti-ligature gown. This left him exposed, a decision was made to clothe him. Whilst e(cid:431)orts were made to clothe Mr Dawes-Clarke, it was suggested that he had kicked one of the paramedics, who then left the cell. The jury went on to record: “For Mr Dawes-Clarke's conveyance to hospital, it was appropriate to attempt to clothe him. However, it was inappropriate to persevere with clothing attempts. The decision making model should have been utilised, and attempts to clothe him should have stopped at the point of resistance. Following the initiation of restraint against Mr Dawes-Clarke, the continued restraint escalated unnecessarily. The prolonged restraint of Mr Dawes-Clarke was inappropriate and disproportionate.” During the restraint of Mr Dawes-Clarke, the paramedics were not in the cell. Prison healthcare were not in the cell either. The jury recorded: “The considerable delay in contacting healthcare to attend throughout the restraint, and furthermore the delay in raising the general alarm caused a significant hindrance. Prison o(cid:431)icers were not able to receive vital medical advice for carrying out the restraint. This demonstrates that the lack of healthcare throughout the restraint was a failure and not in line with prison guidance. The ability of the paramedics to perform their duty of care to Mr Dawes-Clarke during the restraint was limited by their placement and lack of visibility from outside the cell. Furthermore, it was inappropriate for the paramedics to approve the handcu(cid:431)ing of Mr Dawes-Clarke having had no training in mechanical restraint to give such advice.” Mr Dawes-Clarke was handcu(cid:431)ed (something which the jury found to be inappropriate considering his positioning) and he went limp and became unresponsive. Mr Dawes-Clarke had a cardiac and respiratory arrest. The jury went on to record: “There were significant shortcomings from both the paramedics and prison o(cid:431)icers in attendance in their responses to Mr Dawes-Clarke going limp and unresponsive. Specifically, the delay in establishing whether he was breathing and the inaction and further delay when starting CPR. Throughout the whole incident, there was a failure on all parts to communicate e(cid:431)ectively and properly. This includes the way in which emergency calls have to be relayed through the communications systems in prison.” Paramedics did re-enter the cell after a member of prison healthcare (a registered general nurse) attended. Treatment was given and there was a return of spontaneous circulation. Mr Dawes-Clarke was conveyed to Medway Maritime Hospital, having arrested again whilst being taken there. In the emergency department he became asystole and despite e(cid:431)orts at treating him, he died there. The jury found that, “the level of understanding and care from the prison sta(cid:431) was grossly insu(cid:431)icient.” 5. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) As the jury noted, communication between attending prison sta(cid:431), healthcare professionals and paramedics was confused. There was confusion as to who had command and control of the medical emergency, which public body took primacy and the di(cid:431)erence in roles and responsibilities. Those attending the scene did not establish any sort of communication strategy or command structure. During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again. (2) (3) 6. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you as the Secretaries of State for Justice, Health and Social Care have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 23 September 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following interested persons in the inquest touching upon the death of Azroy Dawes-Clarke. I have also sent it to the following who may find it useful or of interest: (i) (ii) (iii) The Chair of the Association of Ambulance Chief Executives; The Chair of the Prison Governors Association; and The Chief Executive O(cid:431)icer of NHS England. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 29 July 2025 Ian Brownhill Assistant Coroner for Kent and Medway
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Parliamentary Under-Secretary of State for Women’s Health and Mental Health 39 Victoria Street London SW1H OEU Department of Health & Social Care Ian Brownhill Kent and Medway Coroners' Service Oakwood House Oakwood Park Maidstone Kent ME16 8AE 25 September 2025 Dear Mr Brownhill, Thank you for the Regulation 28 report of 29 July 2025 sent to the Secretary of State about the death of Azroy Dawes-Clarke. I am replying as the Minister with responsibility for mental health and offender health. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Dawes- Clarke’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. I understand the concerns your report raises about the communication and confusion between prison staff, healthcare professionals and paramedics as to who should have command and control of the medical emergency, and the lack of clarity as to how such a situation could be avoided if a medical emergency happened in a custodial setting again. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address the issues highlighted in your report. Good communications are vital during a medical emergency, and it is important that all professionals concerned understand their roles and responsibilities. I can confirm that HM Prison and Probation Service is the public body which takes primacy for the leadership, command and control of an emergency situation in prison, including a medical emergency. Healthcare staff within a prison should respond to and provide any emergency medical treatment, such as CPR, until a paramedic arrives on scene. In light of the circumstances surrounding Mr Dawes-Clarke’s death, I would like to add that the Care Quality Commission has issued guidance about reducing harm in mental health settings which recognises the risk of non-anchored ligatures. This is available here: https://www.cqc.orq.uk/quidance-providers/mhforum-liqature-quidance. I understand that you have issued a separate Regulation 28 report to the Director General Chief Executive of HM Prison and Probation Service; and one to the Governor at HMP Elmley, Oxleas NHS Foundation Trust and the South East Coast Ambulance Service. I would expect the Ambulance Service to provide more detail about the role of paramedics in medical emergencies within the prison estate. More broadly, as signatories to the National Partnership Agreement for Health and Social Care for England, the Department of Health and Social Care and NHS England are committed to working with partners to reduce health inequalities for people in prison and improving services to ensure that people have access to timely and effective healthcare whilst in prison. I would like to inform you that the Chief Medical Officer for England’s report on health in prisons is due to be published this year and will provide recommendations for further action. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, PARLIAMENTARY UNDER-SECRETARY OF STATE FOR WOMEN’S HEALTH AND MENTAL HEALTH
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