Mohammed Azizi

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Independent investigation into
the death of Mr Mohammed Azizi,
a prisoner at HMP Norwich,
on 15 May 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Mohammed Azizi died in hospital of heart failure on 15 May 2023, while a prisoner at
HMP Norwich. He was 32 years old. I offer my condolences to Mr Azizi’s family and
friends.
The clinical reviewer concluded that the healthcare Mr Azizi received at Norwich was of a
very good standard and equivalent to that which he could have expected to receive in the
community. She found that the healthcare team at Norwich cared for Mr Azizi with
compassion and dignity in difficult circumstances.
I make no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2024
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Contents
Summary .........................................................................................................................1
The Investigation Process ................................................................................................3
Background Information ...................................................................................................4
Key Events .......................................................................................................................5
Findings ...........................................................................................................................8
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Summary
Events
1. On 24 September 2021, Mr Mohammed Azizi was sentenced to five years
imprisonment for arson. On 11 August 2022, he was moved to HMP Norwich.
2. Mr Azizi had Crohn’s disease (inflammatory bowel disease). Before he arrived at
Norwich, he was admitted to hospital for treatment of intra-abdominal sepsis (a life-
threatening inflammation of the stomach) and a suspected bowel obstruction. Mr
Azizi refused to take medication for his Crohn’s disease, iron tablets, or blood
thinning medication for a diagnosed blood clot. While he was in hospital, the mental
health team assessed Mr Azizi and deemed that he had capacity to make
decisions, including unwise ones, about his care.
3. Throughout his time at Norwich, Mr Azizi repeatedly declined medical treatment,
including clinical observations and blood tests, and refused medication. He was
selective in the medication he took (usually he took only his steroid tablet,
prescribed to help with his Crohn’s disease).
4. On 25 August, a GP saw Mr Azizi to as he refused to have his clinical observations
taken by the healthcare team. Mr Azizi told the GP that if he got his category D
status (which would mean he could be placed in an open prison), he would cook for
himself and start eating his own food. He said that he did not like the prison food
and did not want the iron supplements or medication he was prescribed as he did
not need them. The GP told him that with his Crohn’s disease, not eating enough
would place strain on his heart.
5. Despite attempts from healthcare staff to encourage Mr Azizi, he continued to eat
only a limited amount and frequently refused blood tests and clinical observations.
6. On 22 September, Mr Azizi was admitted to hospital with a suspected deep vein
thrombosis (DVT – a blood clot in the vein). While in hospital Mr Azizi refused to
comply with treatment for DVT. A consultant spoke to him to warn of the risks to his
health if he did not accept treatment, however, he declined. Mr Azizi was
discharged from hospital on 13 October as he was not compliant with treatment.
7. On 27 October, a nurse and GP saw Mr Azizi as he was complaining of pain and
was feeling weak and dizzy. The nurse took his clinical observations, which showed
his heart rate was high, and his blood pressure was low. Mr Azizi asked to be taken
to hospital and told healthcare staff that he would now agree to treatment. The
healthcare team called an ambulance, and he was admitted to hospital.
8. On 3 November, a nurse at Norwich spoke to a nurse on the ward who said that Mr
Azizi was not complying with nursing staff and was refusing blood tests. He was
refusing the hospital food that was specifically made for him and was asking officers
to buy food from outside the hospital. He refused to have a CT scan (as he would
need to be nil by mouth) but agreed to have antibiotics. He was discharged from
hospital on 17 November as he would not comply with treatment.
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9. On two occasions in March 2023, Mr Azizi was taken to hospital after healthcare
staff recorded abnormal clinical observations. However, on both occasions, Mr Azizi
refused treatment at hospital and was discharged back to the prison the same day.
10. On 24 April, Mr Azizi rang his personal alarm, and a nurse attended his cell. Mr
Azizi was short of breath and said he was feeling unwell. The nurse took his clinical
observations and Mr Azizi asked to go to hospital. The nurse called an emergency
ambulance which took Mr Azizi to hospital.
11. Mr Azizi was admitted to hospital. He was diagnosed with a lung infection, chest
infection and DVT. He continued to refuse certain aspects of care, despite doctors
explaining to him the risks of his behaviour. The hospital mental health service
assessed him and found that he had no acute mental illness and had capacity to
make decisions.
12. Mr Azizi’s condition continued to deteriorate, and on 15 May, he died in hospital.
13. The post-mortem report concluded that Mr Azizi died from heart failure caused by
malnutrition, Crohn’s disease and self-neglect.
Findings
14. The clinical reviewer found that the care Mr Azizi received at Norwich was of a very
good standard and was equivalent to that which he could have expected to receive
in the community. She found that the healthcare team at Norwich cared for Mr Azizi
with compassion and dignity in difficult circumstances.
15. The clinical reviewer found that there were several areas of good practice in Mr
Azizi’s care including comprehensive mental capacity assessments and
multidisciplinary team working.
16. We make no recommendations.
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The Investigation Process
17. HMPPS notified us of Mr Azizi’s death on 15 May 2023.
18. The investigator issued notices to staff and prisoners at HMP Norwich informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
19. The investigator obtained copies of relevant extracts from Mr Azizi’s prison and
medical records.
20. NHS England commissioned an independent clinical reviewer to review Mr Azizi’s
clinical care at the prison.
21. We informed HM Coroner for Norfolk of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
22. The Ombudsman’s family liaison officer contacted Mr Azizi’s brother to explain the
investigation and to ask if he had any matters he wanted us to consider. He was
concerned that Mr Azizi had not received the correct medical care, which has been
addressed in this report and the clinical review. He raised several issues which fell
outside the remit of our investigation, which we have addressed in a separate letter.
23. We shared our initial report with HMPPS. They found no factual inaccuracies.
24. We sent a copy of our initial report to Mr Azizi’s brother and a translated copy to Mr
Azizi’s parents. Mr Azizi’s brother raised several concerns about Mr Azizi’s care.
The clinical reviewer reviewed these comments and assessed that no factual
inaccuracies had been raised and no changes were required to her report. Mr
Azizi’s brother made some other comments which we have responded to in
separate correspondence.
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Background Information
HMP Norwich
25. HMP Norwich is a multifunctional local prison and young offender institution (YOI)
holding remand and sentenced category B, C and D prisoners. It holds up to 733
male prisoners. The physical health care provider is Health Care Resourcing Group
Limited. Mental health services are provided by Norfolk and Suffolk NHS
Foundation Trust.
HM Inspectorate of Prisons
26. The most recent inspection of HMP Norwich was in August and September 2022.
Inspectors reported that the inpatient unit on L Wing delivered good, personalised
health and social care, however the environment was shabby and not therapeutic
for sick patients.
Independent Monitoring Board
27. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 28 February 2023, the IMB
reported that healthcare was broadly equivalent to that available in the community.
They noted that caseloads for the mental health team were very heavy. They also
commented that accommodation on L Wing and in the healthcare centre was
outdated and would benefit from refurbishment and modernisation.
Previous deaths at HMP Norwich
28. Mr Azizi was the fourteenth prisoner to die at Norwich since May 2020. Of the
previous deaths, 10 were from natural causes and three were self-inflicted.
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Key Events
29. On 24 September 2021, Mr Mohammed Azizi was sentenced to five years
imprisonment for arson. On 1 June 2022, Mr Azizi was moved to HMP Highpoint.
30. Mr Azizi had Crohn’s disease (inflammatory bowel disease). While at Highpoint, he
became unwell with intra-abdominal sepsis (a life-threatening inflammation of the
stomach) and was admitted to hospital for treatment on 6 June. Mr Azizi refused
treatment for a suspected bowel obstruction, despite doctors advising of the
dangers of this, and was discharged back to Highpoint on 11 July.
31. Mr Azizi’s health deteriorated over the next few days, and he was admitted to
hospital on 16 July. While he was in hospital, the mental health team assessed Mr
Azizi and deemed that he had capacity to make decisions, including unwise ones,
about his care. Mr Azizi refused to take medication for his Crohn’s disease, iron
tablets, or blood thinner medications for a diagnosed blood clot.
32. On 11 August, Mr Azizi was discharged from hospital and moved to HMP Norwich,
where there was a 24-hour healthcare service. He was admitted to the prison’s
healthcare unit.
33. On 14 August, a nurse saw Mr Azizi and took his clinical observations, which were
all within the normal range. Mr Azizi continued to decline to take medication that
was prescribed for intra-abdominal sepsis.
34. On 25 August, a GP saw Mr Azizi as he had refused to have his clinical
observations taken by the healthcare team. Mr Azizi told the GP that if he got his
category D status (which would result in a move to an open prison), he would cook
for himself and start eating his own food. He said that he did not like the prison food
and did not want the iron supplements or medication he was prescribed as he did
not need them. The GP warned him that with his Crohn’s disease, he could cause
harm to his body by not eating enough as this would place strain on his heart.
35. Despite attempts from healthcare staff to encourage Mr Azizi, he continued to eat
only a limited amount and frequently refused blood tests and clinical observations.
36. On 5 September, prison staff started suicide and self-harm monitoring (known as
ACCT) as Mr Azizi told both prison and healthcare staff that he wanted to die.
Prison staff started hourly observations and the healthcare team referred him for a
mental health review. (Staff continued ACCT monitoring until 5 November.)
37. On 20 September, a psychiatrist saw Mr Azizi for a capacity assessment due to him
refusing treatment and medication. The psychiatrist found that Mr Azizi was very
physically unwell but had the capacity to make decisions about his care.
38. On 22 September, Mr Azizi was admitted to hospital with a suspected deep vein
thrombosis (DVT – a blood clot in the vein). While in hospital Mr Azizi refused to
comply with treatment for DVT. A consultant spoke to him to warn of the risks to his
health if he did not accept treatment, however, he declined.
39. On 13 October, Mr Azizi was discharged from hospital as he was not compliant with
treatment.
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40. On 25 October, a consultant psychiatrist saw Mr Azizi. He told her that he would
eat, drink and take his medication if he was moved to a category D prison. He was
aware of the potential consequences of refusing treatment, including worsening of
his Crohn’s disease, blood clot, hospitalisation and even death.
41. On 27 October, a nurse and GP saw Mr Azizi as he was complaining of pain and
was feeling weak and dizzy. The nurse took his clinical observations, which showed
his heart rate was high, and his blood pressure was low. Mr Azizi asked to be taken
to hospital and told healthcare staff that he would now agree to treatment. The
healthcare team called an ambulance, and he was admitted to hospital.
42. On 3 November, a nurse at Norwich spoke to a nurse on the ward who said that Mr
Azizi was not complying with nursing staff and was refusing blood tests. He was
refusing the hospital food that was specifically made for him and was asking officers
to buy food from outside the hospital. He refused to have a CT scan (as he would
need to be nil by mouth) but agreed to have antibiotics. Mr Azizi was discharged
from hospital on 17 November as he would not comply with treatment.
43. Between 18 November and 29 December, the healthcare team assessed Mr Azizi’s
mental capacity to make decisions on his healthcare six times and each time
assessed that he had capacity.
44. On 31 January 2023, Mr Azizi was moved to L Wing at Norwich where he could
have social care support with activities of daily living.
45. On 14 March, a nurse saw Mr Azizi and took his clinical observations, which were
abnormal and indicated that he needed to be reviewed at hospital. The nurse called
an ambulance, and Mr Azizi was taken to hospital. Mr Azizi declined all treatments
that were offered in A&E and was therefore discharged the same day.
46. On 21 March, a healthcare assistant saw Mr Azizi as he had been unresponsive
following a bath. She took his clinical observations which were abnormal and
indicated he needed an urgent transfer to hospital. She called an ambulance and
Mr Azizi was taken to hospital. He was discharged back to Norwich the same day
as he refused all treatment.
47. On 26 March, prison staff started ACCT monitoring for Mr Azizi as he refused to
attend hospital for medical treatment. When staff told him that he could die if he did
not go, he said he was fine. Staff stopped ACCT monitoring the next day as Mr
Azizi assured staff that he had no thoughts or intentions of suicide or self-harm. He
was assessed as having mental capacity.
48. On 5 April, a psychiatrist assessed Mr Azizi and deemed that he had mental
capacity to make decisions about his health.
49. On 24 April, Mr Azizi rang his personal alarm, and a nurse attended his cell. Mr
Azizi was short of breath and said he was feeling unwell. The nurse took his clinical
observations and Mr Azizi asked to go to hospital. She called an emergency
ambulance. The paramedics arrived and took Mr Azizi to hospital where he was
subsequently admitted.
50. Mr Azizi remained in hospital. He was diagnosed with a lung infection, chest
infection and DVT. He continued to refuse certain aspects of care, despite doctors
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explaining to him the risks of his behaviour. He was assessed by the hospital
mental health service and was found to have no acute mental illness and had
capacity to make decisions.
51. On 12 May, staff submitted an application for Mr Azizi’s early release on
compassionate grounds (ERCG) to the Public Protection Casework Section (PPCS)
of HMPPS. The same day, PPCS responded and asked for a report from Mr Azizi’s
consultant. This was still outstanding when Mr Azizi died.
52. Mr Azizi died in hospital on 15 May.
Contact with Mr Azizi’s family
53. The prison appointed a Supervising Officer (SO) as the family liaison officer (FLO)
for Mr Azizi. The FLO contacted Mr Aziz’s family on 21 March to let them know that
Mr Azizi had been taken to hospital.
54. On the day of Mr Azizi’s death, the FLO contacted Mr Aziz’s parents to discuss his
declining health. His mother was staying at the hospital with Mr Azizi and did not
want anyone else from the prison to attend or contact her at this time.
55. The FLO arranged for Mr Azizi’s belongs to be returned to his brother. The prison
contributed towards Mr Azizi’s funeral costs in line with HMPPS policy.
Support for prisoners and staff
56. After Mr Azizi’s death, a prison manager debriefed the officers who were on bed
watch with Mr Azizi at the time of his death to ensure they had the opportunity to
discuss any issues arising, and to offer support. The staff care team also offered
support.
57. The prison posted notices informing other prisoners of Mr Azizi’s death and offering
support.
Post-mortem report
58. The post-mortem concluded that Mr Azizi died of cardiac atrophy (decrease in size
and function of the heart muscle) and heart failure caused by malnutrition, Crohn’s
disease and self-neglect. Pulmonary thromboembolism (a blood clot in the lung)
and infarction (death of the lung tissue) were listed as contributing factors.
59. At the inquest, held on 17 April 2024, the jury concluded that 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 continuous
refusal of treatments. They found that Mr Azizi repeatedly refused food, monitoring,
investigations and treatment. The risks to Mr Azizi’s physical health were known to
him and he was judged by multiple professionals to have the capacity to understand
that the outcome of his decisions could result in death.
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Findings
Clinical care
60. The clinical reviewer found that the care Mr Azizi received at Norwich was of a very
good standard and was at least equivalent to that which he could have expected to
receive in the community.
61. The clinical reviewer found that the healthcare team at Norwich provided
compassionate care to Mr Azizi and treated him with dignity, particularly towards
the end of his life.
62. Mr Azizi had comprehensive mental capacity assessments while at Norwich, from
both healthcare and mental health teams, and from external psychiatry. This
ensured accuracy and fairness in his assessment.
63. The clinical reviewer found that healthcare staff from HMP Highpoint travelled with
Mr Azizi from West Suffolk Hospital to HMP Norwich to oversee his transfer of care.
This was very good practice.
Compassionate release application
64. Release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from custody before their sentence has expired. A clear
medical opinion of life expectancy is required. The criteria for early release are set
out in the Early Release on Compassionate Grounds (ERCG) Policy Framework.
Among the criteria is that the risk of reoffending is expected to be minimal, further
imprisonment would reduce life expectancy, there are adequate arrangements for
the prisoner’s care and treatment outside prison, and release would benefit the
prisoner and his family. An application for early release on compassionate grounds
must be submitted to the Public Protection Casework Section (PPCS) of HMPPS.
65. Paragraph 4.25 of the ERCG Policy Framework says, ‘The application must include
a multidisciplinary report completed by all roles currently caring for the prisoner.
This must include, but is not limited to, a report from the prison GP/locum and an
additional report from the medical specialist(s) – this is usually a consultant –
involved in the care of the prisoner. The reports should provide a diagnosis,
assessment of incapacity/frailty, prognosis, treatment pathway/plan and, where
applicable, a clear indication of life expectancy’.
66. On 12 May 2023, the prison submitted an application for Mr Azizi’s release on
compassionate grounds to PPCS, however they did not include a consultant’s
report as required. A PPCS caseworker responded the same day to request a
consultant’s report with the application.
While we accept that this omission had no impact as Mr Azizi’s health deteriorated
rapidly and he died three days later, staff should know the documentation required
when submitting an ERCG application. We bring this to the attention of the
Governor and Head of Healthcare.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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