Azroy Dawes-Clarke

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Independent investigation into
the death of
Mr Azroy Dawes-Clarke,
a prisoner at HMP Elmley,
on 10 November 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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© Crown copyright, 2025
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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 Azroy Dawes-Clarke, a black British man, died on 10 November 2021, at HMP Elmley.
His cause of death was complex and recorded by the pathologist as hypoxic ischaemic
brain injury, due to cardio-respiratory arrest, in close proximity to a period of third-party
restraint, shortly after an apparent seizure following compression of the neck by a ligature.
He was 28 years old. I offer my condolences to Mr Dawes-Clarke’s family and friends.
The circumstances of Mr Dawes-Clarke’s death are concerning. Force was used on him
twice in the time before he died. The first occasion seemingly triggered a chain of events in
which Mr Dawes-Clarke tried to take his life three times in a little over two weeks. The
second occasion occurred immediately after staff found him with a ligature around his
neck, which prompted a confused response in which Mr Dawes-Clarke’s physical
symptoms of seizure and incoherence were mistaken for aggression. Mr Dawes-Clarke
stopped breathing during this use of force and died shortly afterwards.
Suicide and self-harm prevention procedures (known as ACCT), which were initiated when
Mr Dawes-Clarke first tried to take his life, were also confused. Some aspects that are
usually reserved for those judged to be at the greatest risk – such as using alternative
(anti-ligature) clothing and unfurnished (special) accommodation – were implemented, but
alongside a frequency of observations usually used for those judged to be at less
immediate risk. There was no management oversight or authorisation of the use of
alternative clothing or unfurnished accommodation, which is likely to have added to the
confusion about how best to manage Mr Dawes-Clarke’s risk.
I am conscious that this report will make distressing reading for Mr Dawes-Clarke’s family.
While his cause of death is particularly complex, there were critical missed opportunities to
adequately manage his circumstances and I cannot say that better decisions would not
have led to a different outcome.
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 April 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 9
Findings ......................................................................................................................... 20
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Summary
Events
1. On 23 April 2020, Mr Azroy Dawes-Clarke was recalled to prison, having breached
his licence by committing a further offence. He was taken to HMP Elmley. On 2
June 2021, Mr Dawes-Clarke was sentenced to seven years and nine months
imprisonment for robbery. He had been to prison several times before.
2. Mr Dawes-Clarke had a long history of self-harm and suicide attempts, including the
tying of ligatures, throughout his time in prison. He also had several physical health
conditions that required ongoing treatment to manage his symptoms.
3. On 25 October 2021, Mr Dawes-Clarke refused an order to return to his cell after
collecting his medication. He then began to walk slowly towards his cell, during
which time staff used force on him. Shortly afterwards, Mr Dawes-Clarke tied a
ligature around his neck and said that he had intended to end his life. After this
incident, Mr Dawes-Clarke’s mental health appeared to deteriorate. Staff started
suicide and self-harm prevention procedures (known as ACCT).
4. On 8 November, Mr Dawes-Clarke was taken to hospital as he was physically
unwell. He was returned to Elmley after threatening a doctor. Later that day, Mr
Dawes-Clarke was extremely upset; he told staff that his sister had been in an
accident (this information was not correct).
5. On 9 November, Mr Dawes-Clarke barricaded his cell and tied a ligature around his
neck. He pressed his cell bell and staff responded. Mr Dawes-Clarke said he felt
under threat and that other prisoners were going to harm him, and that he wanted to
end his life. Staff placed Mr Dawes-Clarke in alternative (anti-ligature) clothing, and
he was moved to Elmley’s inpatient unit, in a cell with a bed but no other furniture or
bedding (known as special accommodation). Mr Dawes-Clarke remained in
alternative clothing and special accommodation until he died.
6. At around 4.40pm on 10 November, a healthcare assistant responded to Mr Dawes-
Clarke’s emergency cell bell and found him lying on the floor of his cell with a
ligature tied around his neck. She alerted nearby officers, who responded and
radioed a medical emergency. Mr Dawes-Clarke appeared to be having a seizure
and prison doctors treated him with diazepam. They handed over care to
paramedics when they arrived.
7. Prison staff and paramedics decided to put clothes on Mr Dawes-Clarke before he
was taken to hospital. While trying to dress Mr Dawes-Clarke, he became agitated
and lashed out. Staff believed that this was intentional (although it is unclear if this
was the case), and they used force to gain his compliance. Handcuffs were applied,
but he became unresponsive almost immediately afterwards. Healthcare staff
started cardiopulmonary resuscitation (CPR). Paramedics continued resuscitation
and Mr Dawes-Clarke was taken to hospital. On the journey to the hospital, Mr
Dawes-Clarke went into cardiac arrest. At 8.13pm, hospital staff declared that he
had died.
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Findings
8. The ACCT procedures were poorly managed and did little to reduce Mr Dawes-
Clarke’s risk. Observations, particularly in the last 24 hours of Mr Dawes-Clarke’s
life, were not appropriate to his level of risk and support actions – which should
direct and enable staff to reduce risk – were minimal and ineffective. Some aspects
of national policy around the use of special accommodation were not followed,
including that there is no evidence that this was authorised by an operational
manager.
9. In the time before he died, force was twice used on Mr Dawes-Clarke. On one
occasion without proper justification and when it was not reasonable, necessary or
proportionate to the circumstances. The second of these events immediately
preceded Mr Dawes-Clarke’s death, and included some techniques that are
considered dangerous and are not advised by national trainers. The overall
management of this incident was particularly poor, with a lack of clear direction or
involvement of healthcare staff or attending paramedics either before, during or
immediately after Mr Dawes-Clarke became unresponsive.
Recommendations
• The Governor should investigate the quality of and compliance with policy of ACCT
management, including the use of alternative clothing and special accommodation,
in the previous 12 months, identify any improvements required, and devise a robust
plan to deliver those improvements.
• The Governor and Head of Healthcare should ensure that there is clear guidance
and training for all staff on the safe use of force, in particular on all risk factors in
relation to positional asphyxia, that they understand the circumstances in which
force is reasonable and justified, and that they are empowered to intervene when
they feel the need to do so.
• The Governor and Head of Healthcare should ensure that clinical staff are
consulted whenever possible before a use of force and attend any unplanned use of
force as soon as possible, especially where a prisoner has already experienced a
medical emergency.
• The Governor should commission the National Incident Management Unit to review
the use of force on 25 October 2021, and implement any recommendations they
make.
• The Head of Healthcare should ensure that there is always a registered nurse or a
GP present during a medical emergency. Guidance on the role of GPs and senior
managers during an emergency should be developed, detailing guidance on
leadership, handover and what staff must do before they return to their usual duties
or leave the prison.
• The Head of Healthcare should ensure that all healthcare staff understand their role
in an emergency response, including recognising and managing seizures or loss of
consciousness in line with current clinical guidelines, and recording actions taken. A
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local protocol, in line with NICE Guidance should be developed and training
provided to ensure staff at all levels understand what is required.
• NHS England and SECAmb should conduct an investigation into the circumstances
surrounding Mr Dawes-Clarke’s resuscitation, including the actions of paramedics in
attendance.
• The Governor and Head of Healthcare should ensure that all staff involved in a
death in custody, and those that are identified as significant to the deceased, should
be offered support in line with Postvention procedures.
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The Investigation Process
10. HMPPS notified us of Mr Dawes-Clarke’s death on 11 November 2021.
11. The investigator issued notices to staff and prisoners at HMP Elmley informing them
of the investigation and asking anyone with relevant information to contact her. We
received a letter from one prisoner in response asking to speak to the investigator,
but he later declined to speak to us.
12. NHS England commissioned a clinical reviewer to review Mr Dawes-Clarke’s
clinical care at the prison. The investigator and clinical reviewer visited Elmley on 8
December 2021. They obtained copies of relevant extracts from Mr Dawes-Clarke’s
prison and medical records, viewed CCTV and body worn video camera (BWVC)
footage and listened to Mr Dawes-Clarke’s prison telephone calls. The investigator
also obtained a copy of the HMPPS Early Learning Review.
13. We suspended our investigation in December 2021, pending the outcome of a
police investigation. We resumed it in November 2023, when Kent Police told us
that no criminal charges would be brought. The original investigator no longer works
for the PPO, so a new investigator was assigned to investigate Mr Dawes-Clarke’s
death.
14. The investigator obtained copies of the Southeast Coast Ambulance Service
(SECAmb) records (including four separate incident reports submitted after Mr
Dawes-Clarke died), Mr Dawes-Clarke’s hospital record for 8 November 2021, an
Internal Investigation Complaint Report by SECAmb following concerns raised
about attending paramedics (made by the Deputy Governor at Elmley), Kent
Police’s Evidence Review Report and their report to the Coroner.
15. The investigator and clinical reviewer interviewed 22 members of staff in January
and February 2023. We attempted to interview three other members of staff; a
mental health nurse, the healthcare assistant that discovered Mr Dawes-Clarke on
10 November and the prison Imam, but they were not currently working at the
prison and did not respond to our approaches.
16. We informed HM Coroner for Mid-Kent and Medway of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
17. The Ombudsman’s office contacted Mr Dawes-Clarke’s mother to ask if she had
any matters she wanted us to consider. Mr Dawes Clarke’s mother said that she did
not believe that her son had killed himself. She later appointed a legal
representative, and they asked the investigation to consider the following questions:
• Was Mr Dawes-Clarke known to be suicidal?
• Did someone phone Mr Dawes-Clarke to tell him his sister had been involved
in a serious car accident?
• How did Mr Dawes-Clarke acquire two chair legs to assist his self-harm as
the prison have said?
• Why only part of the incident that led to Mr Dawes-Clarke being restrained
was captured on body-worn footage?
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18. Mr Dawes-Clarke’s family received a copy of the initial report. On 19 September
2024, the PPO’s assistant ombudsman, investigator and family liaison officer met
with Mr Dawes-Clarke’s family and their legal representative to explain the
investigation remit and answer any immediate questions. Mr Dawes-Clarke’s family
did not identify any factual inaccuracies. However, via their legal representative,
they raised several issues for the PPO to consider before issuing their final report.
We have considered these submissions carefully and have made some
amendments to the final report as a result. Mr Dawes-Clarke’s family also asked
questions that have been answered in a separate correspondence.
19. Mr Dawes-Clarke’s family asked for the Control & Restraint Instructor to be
removed from her role, pending the outcome of a review by the National Incident
Management Unit, and for disciplinary action to be considered by the Governor. The
PPO shared this request with the Governor. We provided Mr Dawes-Clarke’s family
and legal representative with the prison’s response.
20. We also shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies (although corrected the spelling of the
Governor’s surname).
21. Neither HMPPS nor the PPO received a response from SECAmb in response to our
recommendation.
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Background Information
HMP Elmley
22. HMP Elmley, located on the Isle of Sheppey, holds men who are remanded and
sentenced in six houseblocks with a mixture of single, double and triple cells. In
November 2021, when Mr Dawes-Clarke was at Elmley, IC24 provided healthcare
services. Since April 2022, Oxleas NHS Foundation Trust has provided healthcare
services.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Elmley was in March 2022. Inspectors reported
that staff and prisoner relationships were better than in comparable prisons.
However, use of force had gone up significantly and leaders had not done enough
to understand the reasons for this rise. Inspectors were concerned that a much
larger number of use of force incidents than they usually see were routinely being
classed as “miscellaneous” rather than being put in a more suitable category.
Segregation to manage the most challenging prisoners was used proportionately.
Use of force documentation was not always fully completed and, although body-
worn video cameras were readily available, too many staff failed to activate them
during an incident to provide evidence and support de-escalation. They made a
recommendation to the Governor that staff routinely switch on body-worn cameras
during use of force incidents.
24. Inspectors noted that the safer custody team was well resourced and had recently
introduced some good initiatives and safeguards to identify and support prisoners at
risk. Prisoners supported through ACCT case management were generally positive
about the care they received, although there were some weaknesses in the process
itself. There was an action plan to improve the quality of case management.
25. Inspectors found that against a background of significant workforce challenges,
mental health services had responded positively to prisoners in need of urgent
support. Prisoners waited longer than before the COVID-19 pandemic to access
routine psychological care, but caring staff provided alternative support while they
waited.
26. Inspectors returned to Elmley in February 2023, to undertake an Independent
Review of Progress. They identified that Elmley still had substantial staff shortages.
However, they noted that the use of body-worn cameras during use of force
incidents was now at 95%, far greater than at other prisons, and was described as
excellent. Managers were now routinely using footage to improve de-escalation and
highlight good practice.
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 published annual report, for the year to 31 October 2022, the
IMB reported that weekly use of force scrutiny ensured that restraint was used
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appropriately and safely. They found that use of body worn cameras was more
effective, evidencing the need for force and creating confidence in the system.
28. The IMB noted that the introduction of quality assuring ACCT entries had led to
improved care plans. However, they agreed with HMIP inspectors that not enough
was being done to understand and address the underlying causes of self-harm.
29. The IMB reported that black prisoners were overrepresented in the segregation unit,
with 18% of the segregation population being black, against an overall population of
11%.
Previous deaths at HMP Elmley
30. Mr Dawes-Clarke was the sixteenth prisoner to die at Elmley since November 2018.
Eleven of these deaths were due to natural causes, two were self-inflicted and two
were due to illicit drug use. To the end of June 2023, there have been five deaths
due to natural causes, two self-inflicted deaths and one awaiting classification.
31. In November 2023, a black prisoner located in the healthcare inpatient unit also
died following restraint. His cause of death was cocaine toxicity, and he had an
underlying heart condition, but the pathologist concluded that this, along with
exertion during the restraint, was a contributory factor in his death. Kent Police have
not identified any criminal offences.
Assessment, Care in Custody and Teamwork
32. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses to support prisoners at risk of suicide or self-harm. The
purpose of the ACCT is to try to determine the level of risk posed, the steps that
staff might take to reduce this and the extent to which staff need to monitor and
supervise the prisoner. Checks should be made at irregular intervals to prevent the
prisoner anticipating when they will occur.
33. Part of the ACCT process involves assessing immediate needs and drawing up
support actions to identify the prisoner’s most urgent issues and how they will be
met. Staff should hold regular multidisciplinary reviews and should not close the
ACCT plan until all support actions are completed. Guidance on ACCT procedures
is set out in Prison Service Instruction (PSI) 64/2011 on safer custody.
Alternative clothing
34. Alternative clothing is special clothing made from material which is extremely
difficult to tear into strips to create ligatures. Prison Service Instruction (PSI)
64/2011 instructs that it must only be used as a last resort and that consideration
must be given to whether alternative options (such as placing the prisoner in a safer
cell with reduced ligature points) would be sufficient to mitigate risk. The decision to
use alternative clothing should take into consideration the potential impact it may
have on the prisoner as it is considered dehumanising. If alternative clothing is used
then an urgent ACCT case review must be held, with case review teams
considering any impact on risk and identifying how this can be mitigated through
support actions, with a view to ending its use.
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Special accommodation
35. Special accommodation is a dedicated cell or improvised normal accommodation
with anyone (or more than one) of the following items removed in the interests of
safety: furniture, bedding, sanitation. Special accommodation should only be used
for the shortest necessary time, to prevent a violent or refractory prisoner injuring
themselves or others, damaging property or creating a disturbance. The prisoner
should be informed of the reasons why and anyone being held in special
accommodation must be observed by staff at least five times per hour, at irregular
intervals. Prison Service Order 1700, Chapter 7, clearly states that the duty
governor (or Governor) must give authority before a prisoner is located in special
accommodation.
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Key Events
36. On 8 June 2018, Mr Azroy Dawes-Clarke was sentenced to 51 months
imprisonment for robbery. He had been to prison before. Mr Dawes-Clarke was
released from HMP High Down on 27 March 2020, but recalled on 23 April for
committing further offences and breaching his licence. He was taken to HMP
Elmley. On 2 June 2021, Mr Dawes-Clarke was sentenced to seven years and nine
months for robbery.
37. Mr Dawes-Clarke had a diagnosis of Behçet’s syndrome, an inflammatory disorder
which affects multiple parts of the body, including causing painful sores in the
mouth and inflammation of parts of the eye. This condition is uncommon but not life-
threatening and he was prescribed a range of medications and was seen by NHS
specialists. He also had moderate chronic kidney disease, which required lifestyle
measures and medication.
38. Mr Dawes-Clarke had a diagnosis of personality disorder. He frequently articulated
that this was the reason for his challenging behaviour. He was referred to
psychology services on several occasions but did not always engage in the work.
Mr Dawes-Clarke had been identified as being suitable for a trial of ADHD
medication, he took this for a short period only and stopped at his own request.
Although Mr Dawes-Clarke said he had a diagnosis of Autistic Spectrum Disorder,
there is nothing to support this diagnosis in his medical records.
39. Mr Dawes-Clarke was also diagnosed with depression and at times struggled with
his mental health. He was prescribed an antidepressant (mirtazapine). Mr Dawes-
Clarke also had a long history of self-harm and suicidal behaviour in prison dating
back to 2010. In total, between June 2010 and July 2021, Mr Dawes-Clarke was
supported by ACCT procedures on at least 35 occasions, following threats to take
his own life, low mood, cutting, and being found with tied ligatures (which, on
several occasions, led to a loss of consciousness). His prison record details that Mr
Dawes-Clarke’s self-harming behaviour was associated with times when he felt he
was being treated unfairly and as a means of manipulating his situation. Prison staff
also recorded that Mr Dawes-Clarke was unable to appropriately manage his
emotions. He told staff that he used self-harm and tying ligatures to express his
emotional turmoil.
40. During his time at Elmley, Mr Dawes-Clarke was subject to COVID-19 restrictions,
along with other prisoners, to help stop the spread of the virus. He often complained
about how his physical health was being managed, which often resulted in him self-
harming or tying ligatures and being supported via ACCT procedures.
41. In the months before he died, Mr Dawes-Clarke had regular key work sessions and
met with his Prison Offender Manager (POM). In June 2021, Mr Dawes-Clarke
asked to transfer to HMP Dovegate (which has a therapeutic community to support
reducing risk and offending) and his POM helped him complete an application form.
However, on 5 July, Dovegate informed Mr Dawes-Clarke that he did not meet their
criteria.
42. Over the following weeks, staff recorded that Mr Dawes-Clarke was complying with
the wing regime and that his behaviour had improved. He received positive reports
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from his job in the food packaging workshop and from houseblock staff. Although he
received some negative reports for poor behaviour, Mr Dawes-Clarke had not been
involved in any violent incidents since he had returned to Elmley in April 2020.
43. On 17 September, Mr Dawes-Clarke was sacked from his job as he chose to attend
the gym instead of working. In the following month, he received two negative entries
for returning very slowly to his cell after collecting his medication.
Events from 25 October 2021
44. At around 9.40am on 25 October, Mr Dawes-Clarke was let out of his cell to collect
his medications, but despite being asked several times to return to his cell he
refused. Mr Dawes-Clarke then began to walk towards his cell. CCTV shows him
walking down the stairs on Houseblock 4, accompanied by five officers. Mr Dawes-
Clarke appears to be walking very slowly and is being encouraged to walk faster.
When he reached the landing and was away from the stairs, Officer A initiated
force; she jumped on Mr Dawes-Clarke’s back, with her arms around his neck,
before her colleagues used control and restraint (C&R) techniques to take him to
the floor. CCTV shows that Mr Dawes-Clarke did not offer any resistance, although
staff said in their statements that he was ‘passively resisting’. In her use of force
statement, the officer said, ‘I am well aware of Mr Dawes-Clarke’s behaviour
everyday giving staff issues with his meds. He consistently avoids staff banging him
up (returning him to his cell) and resists against the regime’. She recorded that after
another officer had tried to de-escalate the situation, she placed her hand on Mr
Dawes-Clarke’s back to guide him, but his demeanour became more aggressive as
he did not want to be touched. She described Mr Dawes-Clarke pushing back on
her and that he said, ‘what are you going to do about it?’. She recorded that she
initiated restraint due to his continued passive resistance and because she was
unsure what his next actions would be.
45. Officers took Mr Dawes-Clarke to the segregation unit. He walked to the unit and
was compliant throughout. Staff charged Mr Dawes-Clarke with an offence of using
threatening, abusive or insulting words or behaviour and disobeying a lawful order.
(These charges were not proceeded with because staff had not issued the
documentation to Mr Dawes-Clarke within 48 hours of the alleged offence being
committed.)
46. Soon after arriving in the segregation unit, staff found Mr Dawes-Clarke lying on his
bed in his cell and choking with a ligature tied around his neck. He stated that he
did not want to live and was upset at being in the segregation unit as he believed he
had done nothing wrong. Staff started ACCT procedures and implemented an
immediate care plan. Shortly afterwards, Mr Dawes-Clarke tied another ligature.
Staff observed Mr Dawes-Clarke five times an hour until he could be fully assessed
and placed him in alternative clothing (a gown made from material that is very hard
to tear).
47. A nurse assessed that Mr Dawes-Clarke was not medically fit to remain segregated.
Staff therefore took Mr Dawes-Clarke to the healthcare inpatient unit (IPD) and
allocated him a safer cell (these are specially designed to have minimal ligature
points). The only source of support noted on his ACCT was Mr Dawes-Clarke’s
mother, but he said that he did not want his mother informed.
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48. At 1.00pm, an officer completed Mr Dawes-Clarke’s initial ACCT assessment. Mr
Dawes-Clarke reported feeling anxious about issues outside of prison and that staff
did not understand his mood swings. He said that he had a long history of self-
harm, which was connected to his mental health and stress. Mr Dawes-Clarke said
that he often acted impulsively without thinking of the consequences but that his
actions after he had been restrained were a genuine suicide attempt. He told the
officer that he wanted to move back to Houseblock 4, so that he had his usual
distractions and access to the telephone to call his family for support (a review of Mr
Dawes-Clarke’s telephone records show that he kept in contact with his family while
at Elmley).
49. At 1.25pm, the IPD manager chaired the first ACCT case review. A mental health
nurse, an officer, a Custodial Manager (CM) and Mr Dawes-Clarke attended. Mr
Dawes-Clarke said he wanted to return to Houseblock 4 as he thought he would be
able to manage his mood better and did not want to remain in the IPD. The IPD
manager recorded that the panel considered it was in Mr Dawes-Clarke’s best
interests to return to the houseblock where he would have his possessions, access
to a phone and TV, but explained to him that he had been charged with a
disciplinary offence for the incident earlier in the day and would have to remain
behind his cell door, which Mr Dawes-Clarke accepted. They encouraged Mr
Dawes-Clarke to speak to staff if he needed support. The panel agreed to reduce
the frequency of ACCT observations to a minimum of one per hour. Two support
actions were recorded; Mr Dawes-Clarke to return to Houseblock 4 and for the
mental health in-reach team (MHIT) to attend the next review. The next ACCT
review was scheduled for 1 November.
50. After the ACCT review, the nurse incorrectly recorded in Mr Dawes-Clarke’s
medical record that he was on constant supervision. She also recorded that he had
tied a ligature while in the IPD and had briefly barricaded his cell with a mattress.
(This information was not recorded elsewhere, and we do not know whether it was
accurate.) Later that afternoon, Mr Dawes-Clarke was moved back to Houseblock 4
and was given his own clothes back.
51. On 26 October, the multi-disciplinary mental health team meeting discussed Mr
Dawes-Clarke. They agreed that he would be referred to Bradley Therapy Services
(for talking therapy) and that healthcare staff would attend all ACCT reviews. They
added Mr Dawes-Clarke to their caseload for two to three weeks for ongoing
observation and assessment.
52. On 28 October, an officer recorded that Mr Dawes-Clarkes had covered his
observation panel and refused to collect his medication. As a result, a wing
manager downgraded him to the basic IEP level. (IEP is a three-tier system
designed to encourage and reward good behaviour in prison.)
53. On 1 November, a Supervising Officer (SO) chaired an ACCT review, attended by a
prison chaplain and Mr Dawes-Clarke. Although not recorded on the ACCT
document, a mental health nurse noted in Mr Dawes-Clarke’s medical record that
she also attended the review. The SO recorded that Mr Dawes-Clarke engaged
well, and although still annoyed that he had been restrained, he was more settled
having spoken to the mental health team and the chaplain. Mr Dawes-Clarke said
he had no thoughts of suicide or self-harm. The SO noted that both support actions
had been completed and did not add any new actions. The panel reduced the
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frequency of ACCT observations to hourly during the night and one conversation
per day. The next ACCT review was scheduled for 11 November.
54. On 6 November, the SO chaired an ACCT review, attended by the Head of
Reducing Reoffending and Mr Dawes-Clarke. Nobody from the healthcare team
attended. The review was held because Mr Dawes-Clarke told the SO that he had
received bad news and that his sister had been in a car accident which resulted in
her having her legs amputated. (This information was not correct. We do not know
how Mr Dawes-Clarke received this news, but it is what he told prison and
healthcare staff.) The SO recorded that Mr Dawes-Clarke was extremely upset,
worried, and agitated. He told Mr Dawes-Clarke that he would request for him to
have a telephone call with his brother who was at HMP Wakefield, but this was not
likely to be until the following week.
55. Mr Dawes-Clarke said he did not have current thoughts of suicide or self-harm, but
that they were always in the background. The panel increased ACCT observations
to a minimum of one per hour during patrol state (when prisoners are locked in their
cells and there is a reduced level of staffing) and during the night. In addition, staff
were required to have two quality conversations with Mr Dawes-Clarke each
morning and afternoon. No support actions were added. The SO scheduled the next
review for 8 November.
56. On 7 November, wing staff asked healthcare staff to examine Mr Dawes-Clarke as
he said he had sickness and diarrhoea. The clinical manager for the IPD examined
him and noted his clinical observations were all within in the normal range but that
Mr Dawes-Clarke was anxious and concerned about his kidney issues. She advised
him to drink plenty of fluids.
57. In the early hours of 8 November, Mr Dawes-Clarke told wing staff that he was still
unwell. The emergency response nurse examined him in his cell and noted that Mr
Dawes-Clarke was vomiting and said he had been unwell for two days. Mr Dawes-
Clarke said that he had not passed urine in that time and was now unable to. She
sent Mr Dawes-Clarke to hospital.
58. At 2.50am, an ambulance took Mr Dawes-Clarke to Medway Hospital. He was
escorted by two officers, and restraints were applied. After a hospital doctor decided
to discharge Mr Dawes-Clarke back to Elmley without antibiotics, which he believed
he should have but were not clinically required, Mr Dawes-Clarke became agitated
and threatened to punch the doctor. The escorting officers returned him to Elmley.
59. Between 29 October and 9 November, Mr Dawes-Clarke made nine telephone
calls, which the investigator listened to. (All prisoners’ telephone calls, except those
that are legally privileged, are recorded, and prison staff listen to a random sample.)
These calls were mostly to his mother, but he also spoke to his sister (we do not
know if this is the sister he thought had been in an accident) and a friend. The calls
to his mother and sister were general conversations. The last call Mr Dawes-Clarke
made was to his friend at 9.48am on 9 November. He sounded out of breath and
told his friend not to take any calls if someone rang and said that someone he knew
had been beaten up. His friend did not appear to understand what Mr Dawes-Clarke
was talking about. Mr Dawes-Clarke ended the call after one minute.
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60. At 2.30pm, a CM chaired an ACCT review, attended by a mental health nurse, a
substance misuse worker, a prison chaplain and Mr Dawes-Clarke. The CM
recorded that Mr Dawes-Clarke said that he was upset about his sister, that he had
a personality disorder and that being segregated had triggered a panic attack. Mr
Dawes-Clarke disclosed that he used self-harm as a means of stress relief but was
finding contact with the mental health team helpful. Mr Dawes-Clarke told the
review that he did not want to be on Houseblock 4 but understood that due to non-
association markers with other prisoners at Elmley (because of issues that Mr
Dawes-Clarke was understood to have with some individuals in the community) he
was not able to move to another houseblock. The panel agreed that the number of
observations and conversations should remain the same. No support actions were
recorded. The next review was scheduled for 10 November.
Events of 9 November
61. On 9 November at 12.45pm, during a routine ACCT observation, an officer
discovered that Mr Dawes-Clarke had barricaded his cell door and tied a ligature
around his neck. He radioed a code blue medical emergency code (used when a
prisoner is unconscious or has breathing difficulties). Body Worn Video Camera
(BWVC) footage shows he persuaded Mr Dawes-Clarke to remove the ligature (a
sock) and spoke to him through the cell door. A SO responded to the code blue and
went to Mr Dawes-Clarke’s cell. A general nurse also responded and when Mr
Dawes-Clarke removed the furniture he had placed behind his door, staff entered.
Mr Dawes-Clarke told them he had tied the ligature as he believed people were
trying to get into his cell to attack and kill him. He said he wanted to be moved and if
he was not moved from the houseblock he would continue to tie ligatures. During
the conversation, officers observed that Mr Dawes-Clarke had broken metal chair
legs (from the chair in his cell), hidden in his trousers, which they removed. Mr
Dawes-Clarke explained that these were for his own protection.
62. Staff removed Mr Dawes-Clarke’s clothing to mitigate the risk of further ligature and
gave him alternative clothing. There is no record that this was authorised by an
operational manager. There was no space in the IPD, so staff allocated Mr Dawes-
Clarke a safer cell on Houseblock 1 over the lunch period, until a space became
available in the IPD. They removed the mattress from the cell so that Mr Dawes-
Clarke could not tear the cover to create a ligature. The SO increased the frequency
of ACCT observations to a minimum of once every half an hour.
63. After lunch, staff moved Mr Dawes-Clarke to what is usually a constant supervision
cell in the IPD. (A constant supervision cell has fewer ligature points than a
standard prison cell. It also has a barred gate which can be used instead of a
standard cell door, although for Mr Dawes-Clarke the standard cell door was used.)
Mr Dawes-Clarke’s cell contained a bed, mattress and pillow, but there was no
other furniture and no bedding, so it amounted to special accommodation. Again,
this was not authorised by an operational manager and Mr Dawes-Clarke was not
observed five times per hour in line with national policy on the use of special
accommodation.
64. At 3.30pm, a CM chaired an ACCT review, which was attended by a nurse, the SO,
two officers and Mr Dawes-Clarke. They recorded that Mr Dawes-Clarke’s mental
health appeared to have deteriorated; he was paranoid and convinced other
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prisoners were intent on harming him. Mr Dawes-Clarke said he wanted to be
transferred to another prison. The CM did not record if the review panel thought Mr
Dawes-Clarke was at high risk of suicide or self-harm or why he should remain in a
constant supervision cell when he was not subject to constant supervision (although
his risk was deemed high enough for him to remain in alternative clothing). The CM
did note that a mental health nurse should attend the next review. The review panel
agreed Mr Dawes-Clarke should remain on 30-minute observations until his next
review, which was scheduled for 11 November. No support actions were added.
65. There are no entries in Mr Dawes-Clarke’s ACCT detailing a summary of the events
in the afternoon, or if staff had any meaningful conversations with him in the
evening. Staff recorded that they completed observations twice an hour.
Events of 10 November
66. Mr Dawes-Clarke was meant to be observed twice an hour until his next scheduled
ACCT review. However, the ACCT ongoing record had been amended on 10
November, to show that he should be observed hourly while in patrol state, with two
conversations in the morning and afternoon. We do not know who made this entry,
but despite this, staff continued to record observations twice an hour. There was no
written summary from night staff.
67. An officer recorded in Mr Dawes-Clarke’s ACCT that during the morning he had
pressed his cell bell several times and told staff that he was not getting help for
kidney failure. Officers described him as acting bizarrely and making strange
comments.
68. A nurse told us that healthcare staff were concerned about Mr Dawes-Clarke’s
behaviour as his mental health appeared to be deteriorating. They therefore asked
a psychiatrist at Elmley to assess him. Sometime between 11.00am and 12.00pm,
the psychiatrist visited Mr Dawes-Clarke. She recorded that Mr Dawes-Clarke said
he felt better having been moved to the IPD and that he wanted to see the Imam.
Mr Dawes-Clarke told her that he felt paranoid that other prisoners and staff were
against him but denied having any auditory or visual hallucinations. Mr Dawes-
Clarke said that the news about his sister being in an accident had affected his
emotions.
69. The psychiatrist noted that Mr Dawes-Clarke’s speech was coherent but that his
mental state had deteriorated acutely within the past 24-48 hours. She concluded
that there was no sign of psychosis. She assessed that Mr Dawes-Clarke’s risk of
suicide or self-harm was elevated, that he was aware he was being supported by
ACCT procedures and that he should remain in the IPD for a period of assessment.
She prescribed an antipsychotic (olanzapine) to be taken at night, but this was not
administered to Mr Dawes-Clarke before he died.
70. There is no record in the ACCT document, medical record, or elsewhere of any staff
interaction with Mr Dawes-Clarke during the afternoon, other than routine
completion of his ACCT observations.
71. The investigator watched the available body worn video camera (BWVC) footage
and listened to prison radio transmissions from 10 November. She also obtained
information from the Southeast Coast Ambulance Service (SECAmb). The following
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account has been taken from all sources. There is no closed-circuit television
covering the corridor where Mr Dawes-Clarke’s cell was located.
72. At 4.25pm, an officer completed an ACCT observation and noted that there were no
concerns. Around five minutes later, he gave Mr Dawes-Clarke his dinner.
73. At 4.40pm Mr Dawes-Clarke pressed his cell bell. A healthcare assistant (HCA)
responded and found him lying on the floor with a ligature around his neck. She
shouted for help from nearby staff; she did not call a code blue and she did not stay
with Mr Dawes-Clarke, instead going to get officers from elsewhere on the unit. Two
officers responded, cut the ligature and radioed a code blue medical emergency.
(The police confirmed that the ligature was made from strips of material from Mr
Dawes-Clarke’s pillow, rather than from his mattress cover as some staff believed.)
74. The control room operator requested an ambulance. The investigator and lead
clinical reviewer listened to the recorded telephone conversations between the
control room and the Ambulance Service. When the request was originally made for
an ambulance, prison staff stated it was a ‘code blue situation’. This appeared to
mean nothing to the ambulance call handler and the prison control room were
unable to provide any details about Mr Dawes-Clarke’s medical situation. The
ambulance service called back but were unable to speak to anyone who could
provide any clinical information about the emergency. Finally, there was a call by
the prison requesting an update on the estimated arrival time (ETA) of the second
ambulance. Although the reference for the first call was available, it did not help the
ambulance service to identify that this was not a new request, and no ETA was ever
given.
75. The officers in Mr Dawes-Clarke’s cell observed that he was struggling for breath,
thrashing around, and moving on the floor in an uncontrolled manner. Healthcare
staff responded to the code blue and a nurse and the then Head of Healthcare
attended. Staff moved Mr Dawes-Clarke from lying on his front to his back and they
assessed him. His oxygen saturation was low but quickly improved when he was
given oxygen. Staff were requested to collect emergency equipment.
76. The nurse said that they attached the pads for a defibrillator to Mr Dawes-Clarke’s
chest, although he had a pulse and was breathing. She tried to record his blood
pressure, but he was moving around on the floor and could not stay still. She
noticed he had blood coming from his mouth and thought he may have bitten his
tongue.
77. At around 4.50pm, the then Head of Healthcare asked two GPs at Elmley to assess
Mr Dawes-Clarke, as she had serious concerns about him. Both doctors concluded
he was experiencing seizures, which were continuing. They decided to administer
10mg of rectal diazepam, followed by a further 10mg of rectal diazepam when the
first dose had no effect. Mr Dawes-Clarke continued fitting so they administered
7.5mg of diazepam by injection. (The medical notes do not make clear who
administered the diazepam.) Around five minutes after the third dose of diazepam
was administered, Mr Dawes-Clarke stopped shaking and his muscles and
breathing became more relaxed, but he was still not speaking. The timeframe for
administering the diazepam was estimated to be between 20 – 40 minutes.
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78. At 5.34pm, paramedics arrived at Elmley. (The location of Elmley, availability of
ambulances, and roadworks, all delayed paramedics.) The two prison doctors
provided them with a handover and left the prison. (The nurse and the then Head of
Healthcare had also left the scene at some point.) Paramedics recorded that they
did not observe any marks around Mr Dawes-Clarke’s neck, that his oxygen level
was good and that there were no concerns about his airway. They established his
level of consciousness as 14, using the Glasgow Coma Scale (GCS - an objective
method to determine the conscious state of a patient. Three types of response are
measured (eye, verbal and motor), and are added together to give an overall score.
The lower the score, the lower the patient’s conscious state. The maximum score is
15, showing that the patient is alert, responsive and breathing. Three is the lowest
score, showing no responses). The paramedics noted that Mr Dawes-Clarke did not
spontaneously open his eyes.
79. When one of the paramedics tried to place a blood pressure cuff on Mr Dawes-
Clarke’s arm he was noted to have resisted and pulled his arm away. The
paramedic recorded that Mr Dawes-Clarke was smirking. Paramedics had concerns
about the level of diazepam that had been administered to Mr Dawes-Clarke and
wanted to speak to the prison doctors, but they had already left the establishment.
80. The paramedics decided that Mr Dawes-Clarke should be taken to hospital. One
paramedic went to get a stretcher from the ambulance, while another tried to insert
an oral airway, despite Mr Dawes-Clarke being assessed as fully conscious and
there had been no change in his condition. This was unsuccessful as was an
attempt to insert a nasal airway. Mr Dawes-Clarke was noted to have violently
waved his arms around and no further attempts were made to insert an airway.
Because he had no clothing on, except the alternative clothing, prison staff and
paramedics agreed that, for his dignity, it would be appropriate to try and put some
clothes on Mr Dawes-Clarke’s lower half.
81. At around 6.00pm, two officers attempted to put some boxer shorts on Mr Dawes-
Clarke. They recorded that Mr Dawes-Clarke scratched one officer and kicked the
other. A paramedic also recorded that Mr Dawes-Clarke kicked them (and so the
paramedic left the cell). An officer initiated a restraint to control Mr Dawes-Clarke
and, together with another officer, was joined by four further prison officers who
took part in the restraint. Staff requested assistance from the duty prison manager
as they had initiated a restraint and needed a set of handcuffs. Prison healthcare
staff did not attend.
82. At 6.07pm, seven minutes after they were asked for assistance, the duty prison
manager and a CM (the assistant duty manager) arrived at the incident and
activated their BWVCs. Footage indicates that the assistant duty manager at least
did not appear to hurry to the incident. Two other staff also responded. BWVC
footage shows three paramedics standing in the corridor outside of Mr Dawes-
Clarke’s cell.
83. BWVC footage shows Mr Dawes-Clarke lying still and passively on his back on the
floor, restrained by five officers; an officer did not have hands on Mr Dawes-Clarke
at this point. Mr Dawes-Clarke can be heard making grunting noises, but he did not
speak or make any threats.
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84. The duty manager decided that Mr Dawes-Clarke should be handcuffed and as
there were no Elmley healthcare staff present, the assistant duty manager asked
paramedics waiting outside of the cell if they had any objections to restraints being
applied. They replied that they did not.
85. At 6.09pm, Officer B observed that Mr Dawes-Clarke’s eyes were bulging. The duty
manager replied that perhaps Mr Dawes-Clarke was in medical distress rather than
being non-compliant.
86. At 6.10pm, Officer B encouraged Mr Dawes-Clarke to sit up and asked if he could
breathe okay. The assistant duty manager asked who had been supporting Mr
Dawes-Clarke’s head during the restraint (known as the number one position) and
Officer B replied, ‘Nobody by the look of it’. The officers raised Mr Dawes-Clarke
into a sitting position and the assistant duty manager applied handcuffs to Mr
Dawes-Clarke’s wrists, behind his back. Mr Dawes-Clarke made no sound. Staff
lifted Mr Dawes-Clarke to sit him on the bed, but he became floppy and
unresponsive. The assistant duty manager instructed staff to put Mr Dawes-Clarke
on the floor, in the recovery position, for him to be assessed.
87. At 6.11pm, the assistant duty manager removed the handcuffs, still clearly unsure if
Mr Dawes-Clarke was genuinely unwell or pretending. An officer checked Mr
Dawes-Clarke for a pulse but did not confirm if he found one. Because there were
no prison healthcare staff present, the assistant duty manager instructed staff to
activate the general alarm so that healthcare staff would attend. At the time, Mr
Dawes-Clarke was laid on the floor, not fully in the recovery position. (The
paramedics were still standing outside the cell door, looking in. The assistant duty
manager told us that he was surprised by their reluctance to come into the cell and
assist.)
88. At 6.12pm, the assistant duty manager asked a nurse, who had just arrived in
response to the general alarm, whether they could confirm if Mr Dawes-Clarke was
genuinely unwell or pretending. He added that Mr Dawes-Clarke had a ‘violent
tendency’. He suggested again that Mr Dawes-Clarke might be pretending to be
unwell or might not be breathing.
89. Officer B then confirmed that he could not feel a pulse. At 6.13pm, the nurse
recognised that Mr Dawes-Clarke was in cardiac arrest and started
cardiopulmonary resuscitation (CPR). (This was around four minutes and 21
seconds after the last definite sound was heard from Mr Dawes-Clarke.)
Paramedics also now entered the cell and began providing urgent care to Mr
Dawes-Clarke. He remained in cardiac arrest for approximately 12 minutes before a
heartbeat was detected. We were told that a defibrillator had been attached earlier,
but it was not attached when Mr Dawes-Clarke became unresponsive and without
BWVC footage, we do not know when or why it was removed, or if indeed it had
been attached.
90. At 6.33pm, a paramedic confirmed that Mr Dawes-Clarke had a pulse. At 6.40pm, a
paramedic said to the nurse that he thought the prison GP had given Mr Dawes-
Clarke too much diazepam.
91. At 6.41pm, additional paramedics arrived at the cell. During a handover between
paramedics, they said that they had to use the prison defibrillator, as the ambulance
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crew did not have the correct pads for their machine. At 6.53pm, Mr Dawes-Clarke
was placed on a stretcher and taken to the ambulance.
92. On the journey to hospital, Mr Dawes-Clarke went into cardiac arrest and the
ambulance stopped to provide emergency care. He was stabilised and they
continued their journey, arriving at Medway Hospital at around 7.40pm. Despite
continued efforts, Mr Dawes-Clarke was declared dead at 8.13pm.
93. The investigator was given a copy of a letter that was found in Mr Dawes-Clarke’s
cell. We do not know when he wrote this. The letter was addressed to Mr Dawes-
Clarke’s mother. He wrote that everything he said on the phone was a lie, and that
Elmley had nothing to do with his death. Mr Dawes-Clarke wrote that the reason he
killed himself was because of his medical conditions, the pain he was in and
because of all the hospital appointments. Mr Dawes-Clarke’s family told us that they
do not think that he wrote this letter, based on the handwriting and the language
used.
94. Kent Police investigated the circumstances surrounding the restraint but concluded
that no criminal offence had been committed.
Contact with Mr Dawes-Clarke’s family
95. The prison appointed a family liaison officer (FLO) and a deputy. At 7.55pm, the
FLO phoned Mr Dawes-Clarke’s mother to inform her that he had been taken to
Medway Hospital. She declined the offer of a taxi to take her directly to the hospital.
At 8.15pm, the FLO phoned Mr Dawes-Clarke’s mother to inform her that he had
died. The prison offered ongoing support and to contribute towards the costs of Mr
Dawes-Clarke’s funeral, in line with national instructions.
Support for prisoners and staff
96. After Mr Dawes-Clarke’s death, the then Governor debriefed some of the prison
staff involved in the emergency response to ensure they had the opportunity to
discuss any issues arising, and to offer support. The staff care team also offered
support. Healthcare staff said that they were not offered immediate support and did
not attend any formal debrief.
97. There was no collective debrief with all the staff involved. One of the officers who
escorted Mr Dawes-Clarke to hospital said he was expected to report for duty early
the next morning, despite leaving the prison not long before midnight. Most staff
said the incident was never formerly discussed with them by managers.
98. The response nurse told us he went home after the incident and that he never had
an opportunity to have a reflective discussion with those involved. The psychiatrist
who had assessed Mr Dawes-Clarke on 10 November, found out he had died via a
general email, some days later, and she had to telephone colleagues at Elmley to
find out what had happened.
99. The prison posted notices informing other prisoners of Mr Dawes-Clarke’s death
and offering support. Staff reviewed all prisoners assessed as being at risk of
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suicide or self-harm in case they had been adversely affected by Mr Dawes-
Clarke’s death.
Post-mortem report
100. The post-mortem recorded that Mr Dawes-Clarke’s death was due to a hypoxic
ischaemic brain injury (caused by a lack of oxygen), due to cardio-respiratory arrest
in close temporal proximity (events that occurred relatively close together) to a
period of third party restraint, shortly after apparent seizure like activity treated with
diazepam following compression of the neck by a ligature.
101. The pathologist was unable to conclude whether Mr Dawes-Clarke had already
sustained significant, irreversible, hypoxic ischaemic damage to his brain at the
point the ligature was removed. The pathologist found no evidence of surface or
deep bruising to support that the staff involved in the restraint had used severe or
inappropriate force. The pathologist concluded that the cause of death was
multifactorial and could not identify any single event as being the main cause.
102. Toxicology results detected only prescribed medication.
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Findings
Managing the risk suicide and self-harm
103. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), contains requirements for staff
using ACCT procedures. Staff are required to use ACCT when they identify that a
prisoner is at risk of suicide and self-harm, based on identified risk factors and
triggers. The PSI says that ACCT case reviews should be multidisciplinary where
possible, that a support plan should be completed at the first review, and that it
must reflect the prisoner’s needs, level of risk and the triggers of their distress.
Support actions must be tailored to meet the individual needs of the prisoner, be
aimed at reducing the prisoner’s risk to themselves and be time-bound.
104. During his time in custody, Mr Dawes-Clarke had often been supported using ACCT
procedures. He had several risk factors that increased his risk of suicide and self-
harm, including a recent and escalating history of tying ligatures and self-
strangulation. Mr Dawes-Clarke had harmed himself several times in prison through
various means and was being treated for depression. In the time before his death,
he (incorrectly) believed that his sister had been involved in a serious accident.
105. Staff appropriately started ACCT procedures on 25 October 2021, after Mr Dawes-
Clarke tied a ligature around his neck, and he was still being monitored at the time
of his death. However, we are concerned that the procedures were very poorly
managed and did little to support Mr Dawes-Clarke. We cannot say whether this
would have affected the eventual outcome for Mr Dawes-Clarke, but it might have
helped prison staff identify his risk and produce an effective care plan, aimed at
addressing his issues and reducing his risk.
106. PSI 64/2011 states that during case reviews, the case review team must set and
review support actions to mitigate risk. Support actions could have been set to
address issues that affected Mr Dawes-Clarke’s risk, including his mental health,
impulsive behaviour, and his concerns about his physical health. Support actions
could also have played an important role in helping Mr Dawes-Clarke to contact his
family to help him understand what, if anything, had happened to his sister, which
was a significant trigger for his distress. Towards the end of his life, support actions
could have been used to help plan how Mr Dawes-Clarke’s risk could be managed
to allow him to wear his own clothes or return to a standard prison wing. Two
support actions were set at the first review and noted as completed at the second
review. However, between 1 November and 10 November, no other support actions
were set during the case reviews, despite Mr Dawes-Clarke’s increasingly risky
behaviour and attempts to self-strangulate.
107. Case reviews are also required to set appropriate levels of observations and
conversations. During his ACCT assessment, Mr Dawes-Clarke said that he had
intended to kill himself when he tied a ligature in the segregation unit. Despite the
first case review being just two hours after this suicide attempt, the review reduced
the ACCT observations to one per hour as Mr Dawes-Clarke said he would not self-
harm if he moved back to Houseblock 4. Given that Mr Dawes-Clarke had very
recently attempted to take his life, we do not think that this was an appropriate
assessment of his risk, and observations should have been more frequent.
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108. On 9 November, Mr Dawes-Clarke barricaded his cell and tied a ligature around his
neck, which he said that he did to end his life. Staff increased the frequency of
observations to a minimum of one every half an hour.
109. In the time before he self-strangulated on 10 November, Mr Dawes-Clarke
presented with indicators of increased risk. He had been described as acting
bizarrely and constantly using his cell bell. The prison psychiatrist who had seen
him in the morning, had concerns that Mr Dawes-Clarke showed signs of
developing mental illness, requiring a period of observation and assessment in the
IPD and was at elevated risk of suicide. No one recognised that these factors might
indicate that his risk of suicide had increased, and that the frequency of
observations should be increased.
110. PSI 64/2011 gives examples of when staff should consider placing prisoners under
constant supervision. These include serious attempts and/or compelling
preparations for suicide, or a recent and credible attempt by a prisoner to take their
own life. Given Mr Dawes-Clarke’s behaviour on 9-10 November, staff should have
considered whether he needed to be constantly supervised and documented this
decision. As a minimum, they should have considered whether two observations
per hour was appropriate to Mr Dawes-Clarke’s current circumstances.
Alternative clothing and special accommodation
111. Prison Service Order (PSO) 1700, regarding segregation, defines special
accommodation as a cell in which one or more of furniture, bedding or sanitation is
removed in the interests of safety, to prevent a violent or refractory prisoner from
injuring others, damaging property or creating a disturbance. It states that special
accommodation should be used for the shortest time possible and must be
authorised by the duty operational manager. A record must be kept of the reasons
for the decision, which should be reviewed hourly. Healthcare staff must complete a
health screen to determine if there are any clinical reasons against using special
accommodation. Prisoners being held in special accommodation must be observed
at least five times per hour.
112. PSI 64/2011 says that alternative clothing must only be used as a last resort. Case
review teams must consider through support actions how to mitigate risk and end
the use of alternative clothing.
113. On 9 November, Mr Dawes-Clarke barricaded his cell and tied a ligature around his
neck. He was moved to the IPD into a constant supervision cell (with a standard cell
door rather than a barred gate) and placed in alternative clothing with observation
levels raised to a minimum of two per hour. The cell had no furniture, and his
bedding was removed (although he still had a bed, mattress and pillow), meaning
that Mr Dawes-Clarke was now held in special accommodation. Mr Dawes-Clarke
had used torn strips from his mattress cover to make a ligature on 25 October, and
staff had raised concerns about the risks of these covers. When Mr Dawes-Clarke
was placed in alternative clothing and special accommodation, the removal of his
mattress/pillow covers, which he had demonstrated could be torn, was not
considered.
114. Mr Dawes-Clarke remained in alternative clothing for over 24 hours, without any
bedding or furniture, until he died. There was no evidence that this was reviewed or
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authorised by an operational manager, and he was not observed five times per
hour.
115. Special accommodation should be used to manage violent prisoners, to mitigate the
impact of that risk. Instead, Mr Dawes-Clarke was placed in this accommodation
seemingly to manage his risk of suicide and self-harm. Elmley did not follow
national guidance, did not monitor him in line with this guidance, and did not review
the arrangements or plan how to keep them in place for the shortest possible time.
116. In summary, Mr Dawes-Clarke’s ACCT management was very confused. On one
hand, staff instigated processes that are usually reserved for those prisoners who
are judged to be at the highest risk of suicide and self-harm. At the same time, the
frequency of ACCT observations was that usually seen for someone whose risk is
moderate but not considered to be immediate, and there was no support plan to
mitigate these risks. Senior management oversight that should have happened did
not, which might have allowed for a clearer view of the level of risk Mr Dawes-
Clarke presented.
117. Since Mr Dawes-Clarke died, Elmley has introduced an action plan to improve the
quality of ACCT case management. They have also reviewed their procedures on
the use of alternative clothing and special accommodation. This established that
use of these facilities should be authorised by the duty operational manager, who
should then chair an ACCT case review to identify how to reduce risk and end their
use as soon as possible.
118. HMIP, in their inspection of March 2022, identified that the safer custody team was
well resourced and had recently introduced some good initiatives and safeguards to
identify and support prisoners at risk. Those subject to ACCT measures were
generally positive about the care they received, although there were some
weaknesses in the process itself. There was an action plan to improve the quality of
case management.
119. While we appreciate that Elmley has recognised deficiencies in the management of
ACCT procedures and taken steps to improve practice since Mr Dawes-Clarke’s
death, we are concerned that his ACCT was poorly managed, fell far short of
expected standards, and did little to support him. We make the following
recommendation to ensure similar failings are not repeated:
The Governor should investigate the quality of and compliance with policy of
ACCT management, including the use of alternative clothing and special
accommodation, in the previous 12 months, identify any improvements
required, and devise a robust plan to deliver those improvements.
Use of Force
120. Prison staff applied force to Mr Dawes-Clarke twice in the time before he died: on
25 October 2021, and again immediately before he died. The Prison Service Use of
Force Policy Framework states that force should only be used:
• If it is reasonable in the circumstances;
• If it is necessary;
• If no more force than is necessary is used; and
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• If it is proportionate to the seriousness of the circumstances.
121. The Use of Force Training Manual, Section 11 (Medical) states:
‘Under no circumstances should staff put any body weight on the neck, chest
abdomen or back of the person being restrained. Neither should there be any
hold around the neck as otherwise blockage of the airway can occur, leading
to unconsciousness and death’.
122. The advice then states;
‘Restraint Asphyxia can result from any restraint position where there is
obstruction of the airway or where movement of the rib cage or abdomen is
limited. Examples include: In the prone position – the person’s body weight,
as well as the additional weight of restraining staff, can make movement of
rib cage less effective so only small volumes of air can go in and out of the
lungs. Seated restraints – stomach and other contents of the abdomen are
squashed and may be pushed upward limiting the movement of the
diaphragm and making it difficult to take deep breaths’.
123. During use of force training staff are told that following exertion or when someone is
upset or anxious, the demands of the body greatly increase. If the body cannot deal
with the additional demand for breathing (particularly during or following the stress
of a physical struggle), this is dangerous and may lead to death within a few
minutes. Therefore, the duration of restraint must be kept to a minimum.
Throughout this period, staff must continuously attempt to de-escalate the situation.
124. All staff should be aware that they have a duty of care towards prisoners and should
monitor their welfare throughout the course of any incident. The Use of Force Policy
states that a healthcare professional (when there is one on site) must attend a use
of force incident as a priority, to take an active role in ensuring the medical
wellbeing and safety of a prisoner under restraint, including by providing clinical
advice to the incident supervisor in the event of a medical emergency.
125. The Use of Force Policy Framework also states that BWVC must be used to record
events that could potentially lead to using force, and to record force being used.
126. All the prison officers involved in restraining Mr Dawes-Clarke had Prison Service
training in control and restraint (C&R) techniques and all had completed refresher
training within the previous 12 months. (The investigator was provided with
evidence this training had been completed.) The accounts of the restraints from the
officers involved in both incidents are broadly consistent.
25 October 2021
127. During a review of CCTV footage, the investigator identified that staff had used
force when Mr Dawes-Clarke initially refused to return to, and then slowly walked
towards, his cell on the morning of 25 October. Footage shows that Officer A
jumped on Mr Dawes-Clarke’s back, with her arms around his neck. This is not an
approved C&R technique and could potentially be very dangerous. She recorded
that she initiated force primarily to prevent harm, assault or harm to others.
However, the footage that we viewed does not reflect this and instead shows Mr
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Dawes-Clarke walking passively towards his cell. He does not appear to be
speaking to anyone and is not displaying behaviour that we believe could be
interpreted as threatening or aggressive. No one recorded the events on BWVC.
128. The investigator contacted the then Governor to ask that the use of force for this
day was reviewed. He tasked the Head of Residence, Services and Use of Force,
to review the use of force and provide the investigator with a report of his findings.
129. The Head completed a quality assurance review report. He concluded that the use
of force was reasonable, given the potential disruption to the regime, and noted that
at the time of this incident BWVC’s were rarely used to proactively record incidents
of this nature. He found that Officer A’s actions were not an approved C&R
technique and that her use of the head control was a poor decision. He did not
deem this incident serious enough for escalation to the Deputy Governor for
consideration for a code of conduct investigation. (Officer A has since been
promoted and is now a C&R instructor.)
130. The footage that we have seen is concerning. Mr Dawes-Clarke was returning to his
cell, albeit slowly. We have not seen any evidence that leads us to agree that this
use of force was reasonable, necessary or proportionate to the circumstances.
10 November 2021
131. On 10 November, prison staff and paramedics made the decision that Mr Dawes-
Clarke should be clothed before he was transported to hospital, because he was
naked from the waist down. When two officers attempted to put boxer shorts on
him, Mr Dawes-Clarke lashed out and kicked one officer in the leg. He also waved
his arms scratching the other officer, and a paramedic left the cell as they feared for
their safety. Both officers then attempted to gain control of Mr Dawes-Clarke. We
note that after Mr Dawes-Clarke had ligatured, he never spoke or made any
intelligible sound. Mr Dawes-Clarke was described by healthcare and prison staff as
moving on the floor in an uncoordinated and apparently involuntary manner. After a
seizure (post ictal phase) it is common for individuals to be confused and agitated
and they may have a reduced level of consciousness.
132. The events that led to the restraint being initiated were not captured on BWVC. The
restraint started at around 6.00pm, but only the last three minutes, from 6.07pm,
were captured. Without any evidence from BWVC footage, we are not able to say
whether the restraint was necessary or whether approved C&R techniques were
used at the start of the restraint. The footage we have seen shows the following:
• Mr Dawes-Clarke can be heard making growling/moaning noises; he did not
speak, made no threats, and appeared to be passive throughout.
• The assistant duty manager asked paramedics if it was okay to for Mr Dawes-
Clarke to be cuffed, in the absence of healthcare staff, and one paramedic
responded that he could be. Paramedics are not trained to give such advice in a
prison situation, neither is it clear that they had full details of Mr Dawes-Clarke’s
medical history. Prison healthcare staff were not present for most of the events
with the two prison GPs having left the prison entirely and nurses having left the
scene some time earlier.
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• With his hands cuffed behind his back, officers attempted to sit Mr Dawes-
Clarke up. From what we have been able to establish, he had been lying down
since the ligature was removed at 4.43pm. No advice or clinical observation
appears to have been sought before the decision was made to sit him up.
• Mr Dawes-Clarke was sat up, leaning forward. He remained silent. Mr Dawes-
Clarke quickly became unresponsive when he was lifted from the floor to sit him
on his bed and was laid back down on the floor. Handcuffs were removed, and
he was placed in a rudimentary recovery position.
133. Prison staff told us during interviews that they were aware that Mr Dawes-Clarke
had an extensive history of staff assaults, that they believed that he was being non-
compliant with their instructions and had consciously lashed out. They did not
consider that these movements were involuntary, despite Mr Dawes-Clarke having
been treated with diazepam for a suspected seizure. They were not provided with
any reliable and up to date clinical information about Mr Dawes-Clarke’s level of
consciousness and believed the correct decision was to restrain him.
134. A member of the National Incident Management Unit of HMPPS produced a report
for Kent Police dated April 2023, which reviewed Mr Dawes-Clarke’s restraint. He
noted the small space within the cell and that from BWVC footage, an officer had
one knee resting on Mr Dawes-Clarke’s torso; he was not able to form an opinion
on the degree of pressure being applied through the officer’s knee. The officer said
that he had no recollection of placing his knee on Mr Dawes-Clarke, nobody had
told him to remove his knee during the restraint and he was unaware that this had
been identified until asked during his interview with the PPO investigator.
135. The member concluded there was a possibility that Mr Dawes-Clarke’s actions
[lashing out] could have been associated with him trying to breathe.
136. The Use of Force Training Manual 2015 V2.1 includes the provision for handcuffing
in the seated position. However, all instructors have since been advised to remove
this from training due to the potential risks associated with the seated position, and
notably after a physical restraint when the prisoner is leant forward for handcuffs to
be applied. This advice pre-dated Mr Dawes-Clarke’s death, but the member was
unable to find any documented evidence for when it was formally activated.
137. The member concluded that the use of force techniques used by officers were
proportionate to the risk and followed where possible the training provided to staff,
except for pressure being placed on the torso of Mr Dawes-Clarke and handcuffing
in the seated position.
138. Elmley had not completed their own review of the circumstances leading up to Mr
Dawes-Clarke’s death and none of the officers involved in the restraint had been
offered the opportunity to review events. The response nurse said during interview
that he had not been told that Mr Dawes-Clarke had been restrained until a few
days after his death and was not provided with any details during the resuscitation.
139. The investigator asked the then Governor if a review of the use of force could be
done retrospectively, following Elmley’s current policy of quality assurance reviews.
He instructed the member to complete this review. The member found that, having
read all available statements and reviewed all available BWVC footage, staff
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conduct was good, the speed of response was good, and staff were acting in the
best interests of their and Mr Dawes-Clarke’s safety at the time the restraint was
initiated. The member found no evidence to substantiate any staff misconduct, and
no techniques used which caused deliberate harm to Mr Dawes-Clarke.
140. Nevertheless, the events around Mr Dawes-Clarke’s death are concerning.
Healthcare staff were not involved as they should have been. Mr Dawes-Clarke had
self-strangulated and was unresponsive since. The clinical reviewer concluded that
it was probable that the arm and leg movements he made when officers attempted
to put underwear on him were involuntary, but this does not appear to have been
considered or recognised by staff and they received no assistance from healthcare
staff or the attending paramedics in this regard. Some of the techniques used by
staff were not approved and were particularly dangerous given Mr Dawes-Clarke
was not coherent or fully responsive.
141. The decision to use force should have been subject to a healthcare assessment of
Mr Dawes-Clarke’s clinical state. While it cannot be established definitively whether,
or to what extent, the restraint played a part in Mr Dawes-Clarke’s death, had
paramedics or healthcare staff intervened and reassessed his level of
consciousness, due to the seizures and the medication delivered, it is possible
there would have been a different outcome.
Conclusion
142. Force was used twice on Mr Dawes-Clarke in the time leading up to his death. Both
had significant consequences. The first incident seemingly triggered Mr Dawes-
Clarke to attempt to take his life. The second incident immediately preceded his
death.
143. We do not consider that force was reasonable or necessary in the first incident.
Although staff told us that Mr Dawes-Clarke had a history of violence and assaulting
staff, there had been no such incidents since he returned to prison around seven
months before he died (although we appreciate that he had recently threatened to
punch a hospital doctor). While he had initially refused an order, at the time of the
first use of force Mr Dawes-Clarke was complying with staff instructions to return to
his cell.
144. Mr Dawes-Clarke was a stockily built black man and we note that HMIP’s thematic
review, The experiences of adult black male prisoners and black prison staff,
published in December 2022, showed that statistically black prisoners accounted for
disproportionately more use of force incidents. Figures from Elmley show that, in
2022 (the year for which we were provided data), black prisoners were over-
represented in the use of force. The IMB also noted that black prisoners were over-
represented in some of the more negative aspects of prison life at Elmley, including
segregation and adjudications. In 2021-22, Elmley upheld nearly a third of
discrimination complaints made by prisoners (although these numbers have since
reduced).
145. While we cannot say for certain that Mr Dawes-Clarke’s race was a contributing
factor in the decision to restrain him on 25 October, we cannot discount this. We
make the following recommendations:
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The Governor and Head of Healthcare should ensure that there is clear
guidance and training for all staff on the safe use of force, in particular on all
risk factors in relation to positional asphyxia, that they understand the
circumstances in which force is reasonable and justified, and that they are
empowered to intervene when they feel the need to do so.
The Governor and Head of Healthcare should ensure that clinical staff are
consulted whenever possible before a use of force and attend any unplanned
use of force as soon as possible, especially where a prisoner has already
experienced a medical emergency.
The Governor should commission the National Incident Management Unit to
review the use of force on 25 October 2021, and implement any
recommendations they make.
Body worn video cameras
146. None of the officers present during the initiation of force, in either of these incidents,
used a body worn video camera (BWVC). PSI 04/2017, Body Worn Video Cameras,
states it is mandatory for staff to use BWVCs at any reportable incident (as outlined
in PSI 11/2012, Management and Security of the Incident Reporting System) and
that staff should start recording at the earliest opportunity to maximise the material
captured by the camera.
147. PSI 04/2017 also states that BWVC must be used ‘when a user has or may be
required to exercise force against a person or persons’, and ‘when a user believes
an interaction presents or is likely to present a risk to the safety of the user, other
members of staff or other persons present’. The BWVC Policy Framework states
that, ‘Staff should recognise when a situation is beginning to escalate and must
consider starting to record as early as possible, which may act as a de-escalation
tactic’.
148. We note that HMIP found in February 2023 that there had been significant
improvements made in the use of BWVCs and review of use of force incidents, so
we do not make a separate recommendation.
Clinical Care
149. The clinical reviewers identified that Mr Dawes-Clarke’s long-term physical
healthcare was difficult to manage. They found that while some aspects of his care
were equivalent to that he could expect to receive in the community, others were
not. We do not repeat these recommendations, but the Head of Healthcare should
ensure that they are addressed.
Mental health
150. Mr Dawes-Clarke had diagnoses of personality disorder and ADHD but did not
always engage with his identified treatment programmes.
151. After Mr Dawes-Clarke was restrained on 25 October, he became more paranoid –
about the threat of violence from other prisoners and for the safety of his family. He
began to tie ligatures after a period of stability. The mental health team reviewed
him, and both a mental health nurse and the psychiatrist noted the difference in his
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presentation. Both describe changes in his presentation which they considered
related to possible emerging mental illness, rather than behavioural issues, which
necessitated further observation and review.
152. On 10 November, the psychiatrist prescribed an anti-psychotic medication for Mr
Dawes-Clarke. This was to try to reduce his agitation and observe the response to
the medication closely and would have helped to inform an emerging diagnosis. Mr
Dawes-Clarke never received this medication as the first dose was due on the
evening that he died.
153. The clinical reviewer concluded that the mental health care Mr Dawes-Clarke
received was equivalent to that which he could have expected to receive in the
community. He was seen quickly by the mental health team when his mental health
appeared to decline and had a consultant psychiatrist review. The clinical reviewers
found this was in line with his needs and was a prompt response. While no
diagnosis was immediately apparent, appropriate support was put in place and
medication offered.
Emergency response
Requesting an ambulance
154. When Elmley’s control room contacted the Ambulance Service, they used the term
‘code blue’ which the 999 operator did not recognise, and the control room staff
were unable to provide any details about Mr Dawes-Clarke’s medical situation.
155. The calls between the control room and ambulance service must have been
mutually frustrating. It has been acknowledged by HMPPS nationally that policy and
practice with regard to calling ambulances is not optimal. We are aware of ongoing
work, commissioned by the Director General of HMPPS and in collaboration with
health partners, to address the issue of control room staff immediately calling an
ambulance (following a code blue) and being unable to answer basic questions
about the prisoner’s medical condition. We therefore make no recommendation.
Administering diazepam
156. Shortly after the ligature was cut from Mr Dawes-Clarke, he began to experience
what the two GPs present concluded was a generalised seizure. As the seizure
continued and did not ease, they concluded that they needed to treat him with a
standard approach for ‘status epilepticus’ (a convulsive seizure that continues for
more than five minutes, or convulsive seizures that occur one after the other with no
recovery between), which is by the use of rectal diazepam. They administered two
doses of 10mg. The specific timings of the doses were not recorded, and we cannot
therefore be certain of the gap between the doses. When Mr Dawes-Clarke’s
seizure continued, they gave a third (7.5mg) dose of diazepam as an injection into
his muscle.
157. NICE guidance (NG217 – Epilepsies in children, young people and adults) does not
include advice on the intramuscular delivery of diazepam in these circumstances.
The GPs said that they thought that gaining seizure control was vital and this was
the only other method available to them, as intravenous use was not possible
because it requires full resuscitation facilities, and the paramedics had not yet
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arrived. The total dose of diazepam delivered was 27.5mg. The British National
Formulary notes that the dose range is up to 40mg. Mr Dawes-Clarke was an adult
weighing 113kg and therefore the dose administered was within the acceptable
range.
158. The overall clinical rationale for the treatment was that the longer a generalised
seizure continues the greater the risk of brain damage. The GPs were aware that
the location of the prison meant that ambulances often take a longer time to reach
them than is ideal. The clinical reviewers found that it was beyond the scope of their
review and expertise to consider if the administration of diazepam was the ideal
treatment in these circumstances and has invited His Majesty’s Coroner to seek
further expert advice.
Emergency care following a seizure
159. There were no detailed timings in the medical record of the initial response to the
emergency or the management of the seizure. The entries in Mr Dawes-Clarke’s
medical record by a nurse and both GPs lack detail both of what they saw and what
they did, when compared to what they noted in their statements and to what they
were able to recall at interview. One of the GPs handed over in person to the
paramedics when they arrived at the prison, the other wrote up the record which
was later given to the paramedics. Both GPs then left the prison as it was the end of
their working day (we consider the absence of any prison healthcare staff at the
scene in more detail below).
160. After the GPs left, the paramedics became concerned about the dose of diazepam
administered. The paramedics said that they thought Mr Dawes-Clarke may have
been given an overdose of diazepam (the maximum dose a paramedic can
administer is 20mg). Mr Dawes-Clarke’s pulse was elevated, but his respiratory
rate, oxygen saturation in air and blood pressure were all normal. Paramedics
assessed Mr Dawes-Clarke’s level of consciousness as GCS14, indicating an
almost normal level of consciousness, which would have included obeying
commands and being orientated. Although he was assessed as fully conscious, and
no further concerns had been identified about his airway, paramedics tried to
support his airway by inserting a tube, first into his mouth and when he did not
tolerate this, up his nose. Both attempts failed. The clinical reviewers noted that it is
unclear if simple, less intrusive methods such as head tilt and jaw thrust had been
tried, if there was a concern about Mr Dawes-Clarke’s airway.
161. When paramedics carried out further checks, Mr Dawes-Clarke was uncooperative,
and this was interpreted as conscious behaviour. The clinical reviewers reflected
that it was unclear how the ongoing effects of seizures were considered by the
paramedics or whether they considered that he was post ictal. The clinical
reviewers stated that it was also difficult to reconcile the certainty of the paramedics
that Mr Dawes-Clarke was fully conscious of his actions, when they believed that he
had been given an overdose of diazepam.
162. The clinical reviewers found there was considerable difference between the
assessment by the paramedics that Mr Dawes-Clarke was fully conscious and
knowingly resisting staff, to a man who needed airway support in the form of a tube
being inserted into his throat or nose. Use of oral or nasal airways is very
uncommon in fully conscious patients because an oral airway is likely to induce
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gagging and cannot be tolerated. Nasal airways may be better tolerated. The
clinical reviewers reflected that paramedics were very focused on their view of the
dosage of diazepam that had been administered, with little evidence they
considered, to the same level, the overall condition of Mr Dawes-Clarke who was
post ictal and very likely to be agitated and confused.
163. Two nurses had been redirected back to the routine duties of the prison by the then
Head of Healthcare. The Head had also left the prison as she was aware that the
paramedics were in attendance. This meant that there was no one immediately
available for officers to ask for advice, other than the paramedics. We note that the
prison healthcare team was experiencing staffing issues at this time. However, the
absence of a registered member of prison healthcare staff, or the GPs, during a
medical emergency was not acceptable and, we consider, had serious
consequences for Mr Dawes-Clarke when officers restrained him in the absence of
any ongoing advice about his medical condition from clinicians. We make the
following recommendations:
The Head of Healthcare should ensure that there is always a registered nurse
or a GP present during a medical emergency. Guidance on the role of GPs
and senior managers during an emergency should be developed, detailing
guidance on leadership, handover and what staff must do before they return
to their usual duties or leave the prison.
The Head of Healthcare should ensure that all healthcare staff understand
their role in an emergency response, including recognising and managing
seizures or loss of consciousness in line with current clinical guidelines, and
recording actions taken. A local protocol, in line with NICE Guidance should
be developed and training provided to ensure staff at all levels understand
what is required.
Resuscitation
164. Mr Dawes-Clarke stopped breathing and his heart stopped while he was under
restraint. There was no immediate clinical assessment of his condition when he
went limp at 6.10pm. Officers were unsure if Mr Dawes-Clarke was conscious or
not. There was no prison healthcare member of staff present and although
paramedics were stood immediately outside the cell they were not asked to
intervene, but also did not appear to volunteer to assist Mr Dawes-Clarke.
165. No active resuscitation began until the response nurse initiated this at 6.13pm. He
said in interview that he did not understand why everyone was standing back and
recalled saying something like ‘this is your fucking domain…this is your job’ to the
paramedics.
166. The nurse and the officers undertook chest compressions, while paramedics left the
prison to collect equipment from the ambulance. All three of the paramedics left the
prison at least once to collect equipment from their vehicle. The paramedics did not
appear to take charge of the resuscitation attempt until around 6.23pm, when they
administered adrenalin.
167. While this must have been an unusual case for the ambulance service, we have
been unable to identify if SECAmb undertook any internal investigation with the
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paramedics. Consideration should be given as to the best approach to take in such
cases, so that immediate memory is captured, and any immediate risks can be
mitigated.
168. The actions of paramedics from SECAmb are outside the remit of the PPO
investigation. We cannot say what they thought their role was in advising on
restraint as they did. The clinical reviewer has reflected that the attempts to insert
an airway in a conscious man who was not exhibiting breathing problems were
difficult to understand clinically, and paramedics were possibly over focused on their
(incorrect) view that the maximum dose of diazepam had been exceeded.
169. After Mr Dawes-Clarke’s death, the then Deputy Governor of Elmley submitted a
complaint about the actions of paramedics. The complaint detailed that: prison staff
were concerned about paramedics’ behaviour towards Mr Dawes-Clarke, in that he
was sworn at while a blood pressure cuff was being applied; that paramedics
remained outside the cell when Mr Dawes-Clarke deteriorated, and they should
have recognised signs the situation was a medical emergency; and that some of
their equipment was missing. In response to this complaint, a SECAmb Operations
Manager concluded in a reported dated 19 December 2021, that the complaint was
partially upheld as the correct equipment was missing from the defibrillator (but this
was not the fault of the paramedic crew) but there was no other learning.
170. The clinical reviewers concluded that the overall approach to managing the
resuscitation cannot be seen as acceptable. We make the following
recommendation:
NHS England and SECAmb should conduct an investigation into the
circumstances surrounding Mr Dawes-Clarke’s resuscitation, including the
actions of paramedics in attendance.
Support for staff
171. Healthcare staff told us that they were not invited to a debrief following Mr Dawes-
Clarke’s death. Several healthcare staff and some prison staff told us that they did
not feel properly supported afterwards.
172. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
173. Although Postvention procedures were not routinely adopted at the time Mr Dawes-
Clarke died, the principles of supporting staff were the same. We make the
following recommendation:
The Governor and Head of Healthcare should ensure that all staff involved in
a death in custody, and those that are identified as significant to the
deceased, should be offered support in line with Postvention procedures.
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174. This investigation report sets out a great deal of learning for both prison and
healthcare staff, who told us that they had not had the opportunity to reflect and
discuss events in a guided and supportive manner. The Governor and Head of
Healthcare will want to think broadly about how to ensure the many staff involved
have an opportunity to reflect on the findings of this report.
Governor to Note
First aid training
175. The investigation highlighted that not all custodial managers or supervising officers
are first-aid trained or have been trained to use a defibrillator. (The duty manager
and Officer B said that they had completed first aid training but could not recall the
last time they did, so their training was lapsed. The assistant duty officer and
another officer, who is based in the IPD, had not completed first aid training.) While
nursing staff at Elmley are at the prison 24/7, training staff in basic life saving
techniques, especially those whose role is to respond to and manage incidents,
could be crucial.
Family liaison
176. Mr Dawes-Clarke’s family were upset that they were given inaccurate information
by the prison FLO. In two subsequent deaths at Elmley, issues around FLO contact
have been identified. The Governor must ensure family liaison officers provide the
bereaved family with accurate information, in line with national policy.
Head of Healthcare to Note
177. The healthcare provider at the time, IC24, undertook only a very brief investigation
before the police involvement led to a suspension of a more detailed review. While
a police investigation must take precedence, it should also have been possible to
gather statements of fact, dated and signed from all the healthcare staff who were
involved in the events surrounding Mr Dawes-Clarke’s death to establish a clear
timeline and to identify any immediate issues.
Inquest
178. The inquest into Mr Dawes-Clarke’s death concluded in July 2025. The jury
returned a narrative verdict - from hearing all the evidence presented to us, we
conclude that Mr Dawes-Clarke died from a combination of factors beginning with
the compression of neck via self-inflicted ligaturing. This was followed by a
disproportionate use of force by prison officers during control and restraint which led
to Mr Dawes-Clarke going limp. After restraint, there was insufficient action taken by
prison staff and paramedics upon realising Mr Dawes-Clarke's cardiac and
respiratory arrest. From the body-worn footage, it is evident that prison staff
neglected to consider Mr Dawes-Clarke's head positioning and breathing
throughout the restraint. The poor practice of applying handcuffs while Mr Dawes-
Clarke was in a kneeling position more than minimally increased the risk of
positional asphyxia.
32 Prisons and Probation Ombudsman
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