Man with suspected learning difficulties died aged 22 at HMP Leeds after losing three stone in 48 days

A man who was suspected of having learning difficulties died after losing three stone in 48 days while in custody at HMP Leeds.

By Daniel Sheridan
Sunday, 12th June 2022, 11:37 am

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The Prison Ombudsman described the circumstances of Mr Afzal’s death as "shocking".

On June 17, 2019, Mr Mohammed Irfaan Afzal was remanded in prison custody, charged with assault and breach of a Community Order, and taken to HMP Leeds.

HMP Leeds

Mr Afzal was a healthy weight when he arrived at Leeds, but over the next 48 days, he lost three stone, almost one third of his body weight, and became very underweight.

Mr Afzal weighed 65kg (10st 3lb), a healthy weight for a man of his height, when he arrived at Leeds.

When he died, he weighed 46kg (7st 3lb).

The pathologist noted that Mr Afzal was emaciated and that his poor nutritional state would have increased the risk of him developing a chest infection, the report by Sue McAllister CB found.

Mr Afzal appeared confused throughout his time at Leeds.

Prison staff suspected that he may have a learning disability or mental health issues, but he was never given a full mental health assessment.

He was never seen by the learning disability nurse, despite the need for a referral being noted several times.

He was prescribed antidepressant medication but never collected it, the ombudsman found.

Ms McAllister said: "Although they repeatedly raised concerns, I am very concerned that Mr Afzal was never seen by the learning disability nurse and never received a full mental health assessment.

"The clinical reviewer found that the mental health care Mr Afzal received at 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.

"This is extremely concerning and needs to be addressed urgently."

On August 2, prison staff found Mr Afzal slumped in a chair and called a medical emergency code.

A nurse attended and staff told her that Mr Afzal had not been eating or drinking.

She took Mr Afzal’s clinical observations, which were all normal, and assessed that he did not need to go to hospital so she cancelled the ambulance that had been called.

The next day, prison staff realised that Mr Afzal had a large quantity of uneaten food in his cell.

On August 4 at around 9.18am, an officer found Mr Afzal lying on his bed unresponsive.

Staff and paramedics resuscitated him and he was taken to hospital.

However, Mr Afzal did not regain consciousness and at 10.50am, he was pronounced dead.

Although there were signs that Mr Afzal was not eating or drinking, neither prison or healthcare staff appeared to pay much attention until a few days before his death, by which time his weight had dropped alarmingly, the report stated.

"I am concerned that there was insufficient staff engagement with this vulnerable young man and that, as a result, opportunities were missed to put food monitoring procedures in place and to support Mr Afzal to increase his food and fluid intake", Ms McAllister continued.

"I also share the clinical reviewer’s concerns about the response from healthcare staff when Mr Afzal collapsed two days before he died.

"He was not assessed as fully as he should have been, was not sent to hospital, and was not monitored.

"This was a missed opportunity to identify how physically unwell Mr Afzal had become.

"Poor communication between prison and healthcare staff also played a part in these missed opportunities to recognise and address Mr Afzal’s issues.

"This also needs to be addressed urgently."

Mr Afzal’s family are critical of the prison’s response to Mr Afzal’s father, who said he was told when he telephoned Leeds that Mr Afzal was ‘fine’ and it was Mr Afzal’s responsibility to maintain contact with his family.

Mr Afzal’s family reflected that he had the wrong contact details for his father and therefore could not get in touch, the report stated.

Mr Afzal’s family do not understand why they were not contacted to provide him additional support due to his mental and physical ill-health, and that he would not have been capable of figuring out how to get the right details to contact his father.

The most recent inspection of HMP Leeds was in November/December 2019. Inspectors found that the need for mental health support was high, with 61 per cent of respondents to the HMIP survey saying that they had a mental health problem.

However, only 25 per cent of prisoners said that they had received support for a mental health problem in the prison.

Only 58 per cent of prisoners reported that they were treated respectfully by most staff, and 47% reported some form of verbal abuse from staff.

Inspectors saw some dismissive and potentially intimidating behaviour by staff.

Fewer prisoners from both black and Muslim backgrounds said that staff treated them respectfully.

Mr Afzal was the 19th prisoner to die at Leeds since August 2017. Of the previous deaths, eight were self-inflicted, eight were from natural causes, one was drug-related and one was a homicide.

The ombudsman has previously recommended that the Governor should work with NHS England to ensure that the provision and delivery of mental health services at Leeds is adequate for the needs of the prison’s population.