Inquest into the death of Mohammed Mudhir in HMP Leeds

15 Sep 2016

An inquest jury sitting before HM Coroner for West Yorkshire, David Hinchliff, today concluded that a catalogue of serious failings at HMP Leeds caused or contributed to the death of 25 year old remand prisoner Mohammed Mudhir who was found hanged in the segregation unit of the prison on 21 August 2005 while the balance of his mind was disturbed.

The jury concluded that the prison had significantly failed Mohammed in relation to his care in custody by reason of poor communication between staff, inadequate mental health assessments and a lack of proper staff training and not opening a self harm form (ACCT). The jury found

“there was a culture of complacency in the way that Prison Service Orders were implemented. Tolerances of inadequate practices and the inability to identify and provide appropriate training and support to the staff contributed to the systemic failure. This was evidence by inconsistent completion of paperwork, failure to communicate clearly their expectations and lack of procedures to regularly monitor the level of service provided by the prison and healthcare staff.”

During the six week inquest, distressing evidence was heard about the severe deterioration in Mohammed’s mental health in the five days prior to his death. Mohammed, who had been described as a model prisoner, began to exhibit symptoms of mental illness and self harm, including:-

  • lacerations to his wrists
  • talking incomprehensibly
  • showing incredible strength in an unprovoked attack on staff
  • being impervious to pain
  • failing to communicate with staff or utter a sound despite having pain inflicted on him
  • drinking out of the toilet
  • praying incessantly.

The jury found that

“A full medical assessment was not undertaken and the reasons given for this are unacceptable and therefore his current mental wellbeing and potential physical injuries were not established.”

During the inquest, the jury heard that prison staff had failed to act on warning signs or communicate with each other about what they had seen. Accordingly, those who took over Mohammed’s care were unaware of the earlier signs of deterioration. The nurse who went to Mohamed’s cell door for a few seconds and then declared him fit to be segregated said that a breakdown of communication between nursing staff and a governor put the welfare of prisoners at risk. She and doctor who were supposed to assess Mohammed both admitted that they did not know of the prison service orders which set out their duties and provided guidance. Neither the nurse nor the doctor carried out the required assessments and neither looked at his medical records which documented a history of depression and thoughts of self harm.

The observation logs that the staff kept on Mohammed in the special cell were inaccurate, misleading and false. Mohammed’s deterioration was captured on CCTV, yet staff that were tasked to observe him simply wrote down what they saw and failed to speak with him or notice his deterioration, including pacing the cell, praying incessantly and drinking out of the toilet. Staff contact with Mohammed while he was in the special cell (18 hours) was limited to less than 90 seconds when the door was open. During that time he was not provided with drinking water. He drank out of the toilet 12 times.

The segregation unit was staffed by untrained auxiliary officers at night. Night staff knew that Mohammed had been seen drinking out of the toilet yet failed to take any action, other than report it to day staff, or speak to him. One night officer who was told that Mohammed had been drinking out of the toilet told the jury that it did not concern her as she had seen other prisoners doing it previously and when she brought it to the attention of senior managers, no action was taken. Day staff did not give Mohammed any water or ask him why he had been drinking out of the toilet over night.

The jury heard evidence that it was custom and practice for prisoners to be placed in the special cell overnight, in spite of this being in contravention of prison service orders which stipulate that they should remain there for the shortest amount of time necessary.

Kate Maynard, solicitor for the family, said:

The CCTV film enabled us to see exactly how appallingly Mohammed was treated by prison and medical staff in the segregation unit. Prison staff treated all of the safeguards for segregated prisoners (observation logs, medical assessments, governor and chaplaincy visits) as administrative ‘tick box’ exercises, and kept records that were incomplete, misleading or fabricated. Staff relied on vulnerable prisoners to self report any problems, failing to see for themselves the clear warning signs that Mohammed’s mental health was deteriorating. If staff had bothered to engage with Mohammed, conduct their observations properly, or communicate with each other about what they had seen, Mohammed’s death may have been avoided.

Mohammed’s brother, Musab Mudhir, said:

We have waited 3 ½ years to find out what happened to my brother. The evidence that we have heard over the last six weeks has been shocking. We are appalled that prison officers should have treated Mohammed with no respect, decency or common humanity. Despite the fact that Mohammed had been seen drinking out of the toilet, nobody spoke to him, provided him with a drink, enquired of his welfare or sought medical assistance. One governor said that he would not have treated a dog in the way that my brother was treated.

My family would like to thank the jury and the coroner for their careful and detailed examination of all of the evidence and to the jury for their findings.

Mohammed mother, Ghada Darwood said:

“I am speechless. Despite the unexpected death of my son he still lives in the consciousness of those who knew him. The people who had care of Mohammed were monstrous and ruthless and had no sense of humanity or dignity. What can I say to minds that evaporated and hearts that turned to stone? Is the human being the most intelligent? What about the mother’s heart? Did the human being forget that he is human? I will go back and say how many tears became candles which lightened the darkness of someone who is looking for the future. How many tears became candles and made life and pleasures and happy events and birthdays. I call for human beings to keep remembering always that they are human and they shouldn’t forget this despite their strength and love of life. Everyone who remembers others and good things will live with good things. Because human beings live with everything around them and not with darkness and evil acts and brutality.”

Mohammed Mudhir’s family was represented by Leslie Thomas of Garden Court Chambers and Kate Maynard of Hickman and Rose Solicitors.



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