HMP Leeds failings slammed by Prisons and Probation Ombudsman after 'unacceptable' death of 22-year-old prisoner

Mohammed Irfaan Afzal died after losing three stone in 48 days while in custody at the prison in Armley in 2019.

He had been a healthy weight when he arrived in June but over the next 48 days, he lost three stone - almost one third of his body weight - and became very underweight.

Mr Afzal had weighed 65kg (10st 3lb), a healthy weight for a man of his height, when he got to the prison. He weighed 46kg (7st 3lb) at the time of his death.

A pathologist noted that Mr Afzal was emaciated and his poor nutritional state would have increased the risk of him developing a chest infection.

A recent inquest held at Wakefield Coroner's Court found he died from Acute Bronchopneumonia, with malnutrition, mental health issues and dehydration all factors.

Speaking exclusively to the Yorkshire Evening Post as part of a special report into deaths at HMP Leeds, Prisons and Probation Ombudsman Sue McAllister said the circumstances of Mr Afzal's death were "shocking".

She said she had made several recommendations to the Governor and Head of Healthcare at the prison following her own investigation.

Some of the failings that contributed towards Mr Afzal's death had been identified in previous investigations by Ms McAllister, with her report noting they "should have been addressed urgently by prison and healthcare staff".

Ms McAllister told the YEP that she was concerned about staff at HMP Leeds "underestimating prisoner's risks to themselves" - a feature she has found in multiple deaths at the prison "in recent years".

She said: "Our investigation of Mr Afzal’s death found there were failings in his care at HMP Leeds, and some of these failings had been identified in previous investigations.

"We had made recommendations for action, which should have been addressed urgently by prison and healthcare staff.

"The circumstances of his death are shocking. We made several recommendations to the Governor and Head of Healthcare in this case, and we work closely with HM Inspectorate of Prisons who follow up on these.

"I was very concerned that Mr Afzal never received a full mental health assessment and that HMP Leeds missed the opportunity to identify how physically unwell he had become. This is unacceptable."

The Ministry of Justice told the YEP that it had since put "stringent measures" in place to avoid any other deaths in circumstances similar to Mr Afzal's or those of five other prisoners whose self-inflicted deaths had been investigated since 2019.

A spokesperson said: “Our thoughts remain with the families who have lost a loved one and we have put stringent measures in place to avoid this happening again.

“HMP Leeds has improved staff training on suicide and self-harm and all prisoners are now assigned a key worker upon arrival to the prison, as part of our commitment to improving mental health at the institution.”

The prison has not been inspected by HM Inspectorate of Prisons since December 2019.

In the report produced following that visit, inspectors said they found cramped living conditions were "prevalent" and 92 per cent of prisoners had problems on arrival.

At that time, 56 per cent of officers had less than two years' service and about a quarter had less than one year.

Sixty one per cent of prisoners had difficulties with their mental health, inspectors found.

In the six months prior to the inspection, there had been more than 600 self-harm incidents - a number note to be "much higher than at similar prisons".

Work to improve consistency of assessment, care in custody and teamwork standards had "not been achieved", despite eight self-inflicted deaths in the years since the previous visit.

In her report into Mr Afzal's death, Ms McAllister said the clinical reviewer found the mental health care he had received at HMP Leeds was not equivalent to that he could have expected to receive in the community.

"This is the sixth death at Leeds in two years, where my investigations have reached that conclusion", she added. "This is extremely concerning and needs to be addressed urgently."

Ms McAllister said she continues to "identify failings in the way staff assess the risk of suicide and self-harm", which means some prisoners are not then monitored and supported appropriately.

She added: "HMP Leeds must ensure that mental health assessments are completed, any concerns about prisoners are logged in their prison record and all prisoners are allocated a key worker who engages, motivates and supports the prisoners allocated to them.

"They should action referrals for learning and disability assessments and manage all prisoners appropriately, in line with national guidelines.

"We recognise that there are particular risks in crowded local prisons such as Leeds, where regimes may be poor, the physical environment may not meet standards of decency and safety, and there may not be enough staff to carry out some of the work that supports keeping people safe, for example key work and some out of cell activities.

"Some prisons, including Leeds, have had high numbers of deaths, and HM Prison and Probation Service have introduced policies to provide additional support to those prisons which have a ‘cluster’ of deaths within a particular time frame."