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Inquest into the death of Thoko Shiri, aged 21

An inquest jury has concluded that a series of failings and neglect caused the death of 21-year-old Thokozani Shiri (Thoko).

Posted on 08 June 2022

The inquest into Thoko’s death, before Her Majesty’s Assistant Coroner Michelle Brown, was held at Essex Coroners Court and concluded on Wednesday 8 June, 2022.

Thoko, of Essex, was HIV positive but the prison healthcare failed for months to provide anti-retroviral medication during two periods of imprisonment in 2017 and 2018. He sadly died on 14 April 2019 from an HIV-related infection. His treating consultant in the community gave evidence to the inquest that Thoko was “a young man. HIV is very treatable. It shouldn’t have happened”.

As his health deteriorated, Thoko told a prison officer “I can’t breathe… I need to go to hospital” but an ambulance was not called until five days later.

Thoko Shiri.

Thoko was a prisoner at HMP Chelmsford when he died at Broomfield Hospital on 14 April 2019. He was a young man in a vulnerable position, due to his long-standing diagnosis of HIV, for which he was receiving treatment prior to his imprisonment. His vulnerability was exacerbated by his dependency upon prison healthcare to provide him with life-saving medication.

Thoko was imprisoned at HMP Chelmsford from 13 November 2017 until 19 March 2018. However, he was not seen at an HIV clinic until 13 March 2018 and he did not receive any HIV medication before his release.

Thoko was again imprisoned at HMP Chelmsford from 10 October 2018 until his death on 14 April 2019. On that occasion, he did not attend an HIV clinic until 23 March 2019, and he did not receive HIV medication until 26 March 2019, some 19 days before his death.

The prison healthcare provider, Essex Partnership University Trust (EPUT), were aware that Thoko had HIV throughout both his periods at HMP Chelmsford.

Jury conclusion

When reaching their conclusions, the jury found that five separate failings had probably caused Thoko’s death. The failures identified by the jury included a failure to provide antiretroviral medication to Thoko during both periods of imprisonment, a failure to refer Thoko to an HIV clinic during both periods of imprisonment, and other systemic failings.

The jury also concluded that each of those five areas of failing amounted to neglect. This means that the jury identified a gross failure to provide basic medical attention to Thoko, who was in a dependent position, and that the failure had caused Thoko’s death.

“I can’t breathe”

Thoko became unwell on 7 April 2019. He told a prison officer “I can’t breathe… I need to go to hospital”. Despite that conversation being recorded, that prison officer has still not been identified by the Ministry of Justice. Shortly after Thoko’s death, the family requested that CCTV footage from 7 April be preserved. However, all CCTV footage of 7 April was overwritten and was unavailable to the inquest.

The Coroner was so concerned that the prison officer in question had not been identified by the time of the inquest, over three years later, and the fact that a senior prison governor appeared not to understand the “Code Blue” policy during his evidence to the Inquest, that a formal report on the prevention of future deaths addressing this point will be sent to the Secretary of State for Justice.

Prison governors admitted at the inquest hearings that a “Code Blue” should have been triggered that day meaning an ambulance would have been called, but Thoko was not admitted to hospital until five days later on 12 April 2019.

“Gross insensitivity”

The inquest heard how, upon Thoko’s mother Beauty Shiri’s arrival at the hospital on 13 April, arrangements were not put in place as quickly as they should have been to allow her to see her son before his condition deteriorated. Thoko was already in an induced coma, as he remained until his death, when his mother was finally able to see him. The inquest heard that, whilst in an induced coma, the prison restrained him unnecessarily with handcuffs.

When Thoko’s mother was finally allowed to see him, he was chained to the bed and barely recognisable to her. She stayed at his side until he died 12 hours later.

The Prison and Probation Ombudsman concluded in a damning report that “this is a case in which a young man died a preventable death as a result of what I can only describe as neglect by healthcare staff, and whose mother was then treated with gross insensitivity by prison staff”.


Thoko’s family have issued the following statement:

“Thoko was just like any young man– he loved life, his friends and family. He was exploring what the world had to offer him, but he ended up on the wrong side of the law, culminating in a short-term custodial sentence. As a family we had great hopes that this would allow him to reflect and look to a brighter future. This was not to be, as a short-term prison sentence turned into a death sentence. Thoko was denied very basic care that would have enabled him to live his life despite his long-term condition.

“We are saddened as we know that people with his condition do not have a reduced life expectancy and that, with basic management, his condition was not fatal.”

Deborah Gold, Chief Executive of National AIDS Trust said:

“Thoko’s death was heartbreaking and completely avoidable. This jury conclusion underlines how many crucial opportunities were missed leading to his entirely preventable death.

“It is shocking that a young man died whilst in the care of the state from a condition that is entirely treatable. Most people with HIV in the UK live long healthy lives. It is absolutely essential that all state places of detention including prisons and immigration detention centres, have robust systems in place to identify, treat and support detained people living with HIV. It is now incumbent upon all bodies responsible for the care and treatment of prisoners and detainees to ensure this happens. As Thoko’s death shows, failure to do so has devastating consequences.”

Selen Cavcav, Senior Caseworker at INQUEST, said:

“This is a very disturbing case which raises serious issues around the failure to provide basic health care to a young black man. This is not the first neglect conclusion against this prison nor is it the first neglect conclusion involving EPUT whose actions are already a subject to an independent inquiry. It’s only through proper culture change and corporate accountability that further deaths can be prevented”

Leigh Day solicitor Maya Grantham, who represents Beauty Shiri, said:

“Thoko was a young man, who was dependent on EPUT to provide basic medical care that would have saved his life. However, despite knowing Thoko had HIV, that basic medical care was not provided by EPUT to Thoko during two separate periods of imprisonment. The circumstances of Thoko’s preventable death must never be repeated, and it is hoped that this inquest investigation has shone a light onto those circumstances to ensure that will be the case.”

Leigh Day instructed Adam Wagner of Doughty Street Chambers to represent Thoko’s family.

Maya Grantham
Discrimination Human rights Inquests Judicial review Prisons

Maya Grantham

Associate solicitor in the prison team

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