Positional Asphyxia and Restraint Death at HMP Belmarsh - Jury Find Healthcare Guilty of Neglect

Monday 6 July 2009

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Sitting before HM Deputy Coroner for London (Inner South), Andrew Walker
HM Coroner's Court, Tennis Street, London SE1 1YD

The inquest into the death of 25 year old Godfrey Moyo, whilst on remand at
HMP Belmarsh, concluded today with the jury deciding that the medical cause
of his death was
(a) positional asphyxia with left ventricular failure following restraint
and (b) epilepsy.

In their damning narrative verdict the jury found that:

"On 3 January 2005 at approximately 2.50am at Belmarsh prison 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 vigorous
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 2 ml 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.

The second nurse and prison officers re-entered the cell and discovered that
Mr Moyo was not breathing.

CPR was commenced and an ambulance was called at 4.45 am. However
resuscitation by staff at the prison, paramedics and hospital staff failed
to revive Mr Moyo."

Lomaculo Moyo, Godfrey's sister, commented:

"I have waited four and half years to hear what happened on 3 January 2005
in HMP Belmarsh. I have been brave enough to sit here to hear painful
evidence of the appalling and inhumane way that my brother was treated by
prison staff including nursing staff at HM Belmarsh.

The jury's verdict reflects the shocking evidence of what happened on 3
January 2005.

Godfrey was failed by a system that was meant to protect him - if staff had
been doing their job properly his death could have been avoided."

Deborah Coles, Co-director of INQUEST said:

"Dangerous restraint methods and neglect caused Mr Moyo's death. He was
treated as a discipline and control problem rather than a human being in
urgent need of medical treatment and care. The responsibility for his death
rests with the Prison Service and we await their response to this damning
verdict. INQUEST will be raising the serious issues in this case at a policy
and parliamentary level."

When explaining why he would make a detailed report (under Rule 43 of the
Coroners Rules 1984) in due course to ministers about how similar deaths can
be avoided in future, HM Deputy Coroner said 'where do I start?' and said he
was concerned by the 'complete lack of understanding of epilepsy among the
staff including medical staff' - and 'this seems to be a system that was
fundamentally flawed.'

The evidence that the jury heard included the following:

- Despite the fact that Godfrey Moyo suffered seizures twice in HMP Belmarsh
(July and October 2004), there was no adequate care plan in place and no
risk assessment, particularly as regards post-ictal violence
- On the evidence of one nurse, the two nurses did not speak to each other
at all; From the time that the nurses were together on the landing outside
Godfrey Moyo's cell to when he was found dead in the cell in the Health Care
Centre (i.e. a period of approximately 1.5 hours)
- One officer's evidence was that Godfrey Moyo was restrained until
unconscious
- All the officers gave clear evidence that they left Godfrey Moyo in the
prone position for longer than absolutely necessary
- Godfrey Moyo had unexplained injuries to his neck which one pathologist
gave evidence were caused beyond reasonable doubt by compression of his neck
- Recovery position is the only safe position in which to place an
unconscious person
- That staff failed to use a trolley although it was available
- Some of the officers who gave evidence said that they were unable to
recognise trigger signs of positional asphyxia notwithstanding their
training
- That Godfrey Moyo was not given the most appropriate medicine for his
condition (rectal diazepam), despite the pharmacist finding it the following
day.

Godfrey Moyo's family is represented by INQUEST Lawyers Group members,
barrister Leslie Thomas of Garden Court Chambers instructed by Daniel
Machover of Hickman and Rose Solicitors.

Notes to editors:

INQUEST has monitored a disproportionate number of deaths following
restraint involving people from Black and Minority Ethnic communities This
is the first restraint related death in prison since the deaths of three
black men in prison in 1995, Dennis Stevens in Dartmoor prison on 11th
October 1995, Kenneth Severin in HMP Belmarsh on 16 November 1995 and Alton
Manning on 8 December 1995. See www.inquest.org.uk

INQUEST is the only organisation in England and Wales that provides a
specialist, comprehensive advice service on contentious deaths and their
investigation to bereaved people, lawyers, other advice and support
agencies, the media, parliamentarians and the wider public. Its casework
priorities are deaths in prison and in police custody, in immigration
detention and in secure training centres. INQUEST develops policy proposals
and undertakes research to campaign for changes to the inquest and
investigation process, reduce the number of custodial deaths, and improve
the treatment and care of those within the institutions where the deaths
occur.

Epileptic prisoner died after being held down by guards
Godfrey Moyo, an epileptic prisoner, suffocated after being held face down
by guards at a high security prison, an inquest has found.

Mr Moyo, 25, died at HMP Belmarsh in south east London in January 2005 after
a series of seizures.

A jury at Southwark Coroner's Court today delivered a narrative verdict
which said that two nurses failed to monitor his condition properly as he
was restrained, campaign group Inquest said.

Prison officers were also unable to spot signs of physical distress, the
panel said.

Mr Moyo suffered an epileptic fit in his cell in the early hours of the
morning, and in the wake of the seizure had a behavioural disturbance during
which he attacked his cellmate and struggled with guards.

He was then restrained and had two further seizures while pinned to the
floor.

While unconscious, Mr Moyo was carried to the prison's intensive care cell
where he was left kneeling against a bed.

He was then injected with a sedative, and died within 20 minutes.

Mr Moyo's sister Lomaculo Moyo said: "I have waited four and a half years to
hear what happened on 3 January 2005 in HMP Belmarsh. I have been brave
enough to sit here to hear painful evidence of the appalling and inhumane
way that my brother was treated by prison staff, including nursing staff at
HMP Belmarsh.

"The jury's verdict reflects the shocking evidence of what happened on 3
January 2005.

"Godfrey was failed by a system that was meant to protect him - if staff had
been doing their job properly his death could have been avoided."

The jury found that the cause of his death was positional asphyxia with left
ventricular failure following restraint, and epilepsy.

Deborah Coles from Inquest, a group which campaigns over deaths in custody,
said: "Dangerous restraint methods and neglect caused Mr Moyo's death. He
was treated as a discipline and control problem rather than a human being in
urgent need of medical treatment and care.

"The responsibility for his death rests with the Prison Service and we await
their response to this damning verdict. Inquest will be raising the serious
issues in this case at a policy and parliamentary level."

A Ministry of Justice spokesman said: "Like every death in custody, Godfrey
Moyo's death at HMP Belmarsh on 3 January 2005 is a tragedy and our
sympathies are with his family and friends.

"The National Offender Management Service (Noms) will now carefully consider
the inquest findings to see what lessons can be learned."

Deborah Coles, Co director, INQUEST
office: 020 7263 1111
mobile: 07714 857 236

Daniel Machover, Hickman and Rose Solicitors
office 020 7700 2211
mobile 07773 341 096

 

 

 

 

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