Godfrey Muzhuzha

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Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Godfrey Muzhuzha,
a prisoner at HMP The Mount,
on 3 May 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Godfrey Muzhuzha died on 3 May 2021 at HMP The Mount. The cause of his death
was pulmonary thromboembolism (a blocked blood vessel in the lungs) due to deep vein
thrombosis. He was 51 years old. I offer my condolences to Mr Muzhuzha’s family and
friends.
The clinical reviewer concluded that Mr Muzhuzha’s clinical care at The Mount was
equivalent to that which he could have expected to receive in the community. However,
she found some deficiencies in assessing and monitoring the severity of his illness when
he became ill the day before his death.
I am concerned that operational staff did not comply with the mandatory policy to call a
medical emergency response code when Mr Muzhuzha first reported breathing difficulties.
It is important to follow the expected medical emergency procedures in all cases and vital
when there are no healthcare staff on duty for immediate help and advice.
The investigation also found that although the prison reimbursed the cost of repatriating Mr
Muzhuzha’s body to Zimbabwe, there was no offer of a contribution to his funeral
expenses.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman March 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 6
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Summary
Events
1. Mr Godfrey Muzhuzha, a Zimbabwean national, had been in prison since 26 April
2005, serving life imprisonment for murder. He had no significant health conditions.
2. On 2 May 2021, Mr Muzhuzha was unwell with a persistent cough, fever and shiver.
Healthcare staff suspected he had caught COVID-19.
3. At around 6.15pm on 3 May, Mr Muzhuzha’s cell mate asked for help, as Mr
Muzhuzha was short of breath. Officers spoke to him and planned to conduct
welfare checks every 15 minutes. A few minutes later, Mr Muzhuzha became
unconscious. The officers returned to his cell and began cardiopulmonary
resuscitation (CPR). Paramedics attended and took over the resuscitation attempts.
However, at 7.28pm, they confirmed that Mr Muzhuzha had died.
Findings
4. The clinical reviewer concluded that Mr Muzhuzha’s clinical care was of a
reasonable standard and equivalent to that which he could have expected to
receive in the community. However, she found that the nurse who reviewed him
when he became unwell recorded no clinical observations and did not use a formal
clinical assessment tool to monitor the severity of his illness.
5. We are concerned that staff did not follow the mandatory requirement to call a
medical emergency response code when Mr Muzhuzha first reported breathing
difficulties. Use of the code would have triggered a request for an ambulance and
advice from the ambulance service call handler before he lost consciousness.
6. Although the prison paid for Mr Muzhuzha’s body to be repatriated to Zimbabwe,
there is no evidence that staff offered to contribute to the costs of his funeral.
Recommendations
• The Head of Healthcare should ensure that clinical observations are taken and
recorded when a prisoner is unwell.
• The Head of Healthcare should ensure that healthcare staff consistently use the
National Early Warning Score 2 (NEWS2) to assess prisoners who are unwell and
identify any clinical deterioration.
• The Governor should ensure that all staff are fully aware of and understand their
responsibilities in a medical emergency, including the use of an emergency
response code if a prisoner has breathing difficulties, or is unresponsive.
• The Governor should ensure that staff offer reasonable funeral expenses, in
addition to repatriation costs, if a deceased foreign national prisoner is repatriated.
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The Investigation Process
7. The PPO issued notices to staff and prisoners at HMP The Mount, informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
8. NHS England commissioned an independent clinical reviewer to review Mr
Muzhuzha’s clinical care at the prison.
9. The initial investigator obtained copies of relevant extracts from Mr Muzhuzha’s
prison and medical records. Another investigator completed the latter stages of the
investigation.
10. We informed HM Coroner for Hertfordshire of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
11. The Ombudsman’s family liaison officer contacted Mr Muzhuzha’s family
representative to explain the investigation and to ask if they wanted to receive a
copy of the investigation report. They did not respond.
12. We shared our initial report with HM Prison and Probation Service (HMPPS). They
found no factual inaccuracies.
13. At an inquest held on 11 April 2024, the Coroner concluded that Mr Muzhuzha died
of natural causes.
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Background Information
HMP The Mount
14. HMP The Mount is a medium security prison holding around 1000 men. Practice
Plus Group provides primary care and mental health services and coordinates the
work of other providers. No healthcare staff are on duty overnight.
HM Inspectorate of Prisons
15. The most recent inspection of HMP The Mount was in March 2022. Inspectors
reported that there was an appropriate range of primary care services in the
healthcare centre, as well as community-based services on the wing. Healthcare
staff were conscientious and knew patients well. However, training and regular
clinical supervision had been interrupted by the COVID-19 pandemic.
Independent Monitoring Board
16. 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 annual report, for the year to 28 February 2022, the IMB
reported that healthcare services were working well and there had been significant
improvement since the COVID-19 restrictions ended.
Previous deaths at HMP The Mount
17. Mr Muzhuzha was the fifth prisoner at The Mount to die since May 2019. Two of the
previous deaths were from natural causes, one was self-inflicted, and one was
drug-related. There have since been six deaths, two from natural causes, two self-
inflicted, one drug-related and one to be determined. There are no similarities
between the findings in this investigation and those of the previous deaths. We
have previously raised the use of medical emergency codes at The Mount.
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Key Events
18. Mr Godfrey Muzhuzha, a Zimbabwean national, was remanded to prison on 26 April
2005. He was convicted of murder on 6 December and sentenced to life
imprisonment, with a tariff of 15 years. Mr Muzhuzha spent time in several prisons
and transferred to HMP The Mount on 26 April 2013.
19. Mr Muzhuzha temporarily transferred to HMP Hewell on 5 November 2019, to
attend court hearings. He returned to The Mount on 2 December. Initial and
secondary health screens identified no health concerns and he had little contact
with the healthcare department over the next 17 months.
20. In the early hours of 2 May 2021, Mr Muzhuzha rang his cell bell and told an officer
that he felt unwell, with a persistent cough, fever and shivering. Staff suspected he
had symptoms of COVID-19. He was advised to self-isolate, rest and alert staff if he
felt worse.
21. When a nurse arrived for duty that morning, the custodial manager informed her
that Mr Muzhuzha was unwell, so she placed him on the emergency list. In the
afternoon, a nurse assessed him and recorded his symptoms. She took a swab to
be tested for COVID-19 and gave him a packet of paracetamol. (The test result later
returned as negative.)
Events of 3 May 2021
22. On 3 May, an officer delivered Mr Muzhuzha’s lunch and evening meal at 11.40am
and 4.00pm, respectively. Mr Muzuzha said he felt alright, and the officer had no
concerns about him.
23. At around 6.15pm, Mr Muzhuzha’s cell bell was pressed, and an officer responded.
His cell mate said that Mr Muzhuzha was having difficulty breathing, and the officer
saw that he was short of breath. As healthcare staff were not on duty at that time,
the officer consulted a custodial manager, who advised him to wait for the alarm bell
responders before going into the cell.
24. A supervising officer and two officers arrived. Mr Muzhuzha was lying on the floor
and told the staff that he had been struggling to breathe for around half an hour.
They told him that he would be monitored for 30 minutes, with wellbeing checks
every 15 minutes and if he was no better at the end of that time, they would call an
ambulance. They advised his cell mate to press the bell if he needed help in
between visits.
25. Around five minutes after the officers left the cell, Mr Muzhuzha’s cell mate rang the
bell again and they all returned. Mr Muzhuzha was still on the floor, in a different
position, face down, unresponsive, with blood trickling from his nose. The officers
placed him on his back and a faint pulse was detected. In a statement, the
supervising officer said he called a code blue (a medical emergency code which
indicates a prisoner is unresponsive or has breathing difficulties) and a code red (to
indicate severe bleeding). He explained that he had called both codes to make it
clear that the situation was serious and also messaged over the radio that an
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ambulance was required urgently. The four staff started CPR, taking turns to
perform chest compressions.
26. An entry in the communications room log at 6.35pm noted, “ambulance required
and called”. Paramedics arrived at 6.46pm and continued the resuscitation
attempts. At 7.28pm, they confirmed that Mr Muzhuzha had died.
Contact with Mr Muzhuzha’s family
27. At around 9.30pm, the prison’s family liaison officer contacted the friend Mr
Muzhuzha had nominated as his next of kin, to break the news of his death. On 4
May, arrangements were made to notify Mr Muzhuzha’s children. On 5 May, his
friend withdrew from acting as next of kin.
28. On 11 May, the prison’s senior chaplain notified the Zimbabwean Embassy. She
asked embassy staff to check whether Mr Muzhuzha’s mother knew about his death
and her wishes if he were to be cremated.
29. Mr Muzhuzha’s family later instructed solicitors and another person to represent
them. On 20 May, they asked what financial help was available towards the funeral
and repatriation to Zimbabwe. The prison reimbursed the costs of repatriating Mr
Muzhuzha.
Support for prisoners and staff
30. After Mr Muzhuzha’s death, a debrief was held for the staff involved in the
emergency response, to ensure they had the opportunity to discuss any issues
arising and to offer support. The prison posted notices informing staff and other
prisoners of Mr Muzhuzha’s death and how to access support.
31. Mr Muzhuzha’s cell mate received support from prison Listeners and Samaritans.
Post-mortem report
32. The post-mortem report concluded that the cause of Mr Muzhuzha’s death was
pulmonary thromboembolism (a blocked blood vessel in the lungs) due to deep vein
thrombosis.
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Findings
Clinical care
33. The clinical reviewer concluded that the care Mr Muzhuzha received at The Mount
was of a reasonable standard and equivalent to that which he could have expected
to receive in the community. However, she found some weaknesses in clinical
processes which the Head of Healthcare will need to consider. Full details of her
findings are in the clinical review report and we reflect those linked to Mr
Muzhuzha’s cause of death.
Clinical observations and use of the National Early Warning Score 2
34. A nurse noted symptoms of breathlessness and fever when she reviewed Mr
Muzhuzha on 2 May, but she recorded no clinical observations. The clinical
reviewer considered that she should have checked Mr Muzhuzha’s temperature,
respiratory rate and blood oxygen saturation levels. (She also highlighted a
previous assessment on 31 December 2020, when no clinical observations were
taken.)
35. The clinical reviewer also considered that a National Early Warning Score 2
(NEWS2) should have been calculated. (NEWS2 is a clinical assessment tool to
help determine the severity of a patient’s illness and identify any deterioration.) We
recommend:
The Head of Healthcare should ensure that clinical observations are taken
and recorded when a prisoner is unwell.
The Head of Healthcare should ensure that healthcare staff consistently use
the National Early Warning Score 2 (NEWS2) to assess prisoners who are
unwell and identify any clinical deterioration.
Emergency response
36. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
and The Mount’s local guidance sets out the actions staff should take in a medical
emergency. This includes a mandatory requirement to use a code system if a
prisoner has breathing difficulties or is unresponsive, to ensure that an ambulance
is called immediately. The guidance states that there should be no delay, as an
ambulance can be cancelled if not needed.
37. The staff who went to the cell when Mr Muzhuzha first reported difficulty breathing
were clearly concerned about his health and shortness of breath, as they planned to
conduct 15-minute checks. However, they did not call a code blue at that time.
When Mr Muzhuzha was later found unresponsive, a supervising officer called code
blue and red calls, but they were not recorded in the communications room log.
38. We acknowledge that it can be difficult for operational staff to determine the severity
of symptoms and that the officers thought the best course was to actively monitor
Mr Muzhuzha. However, the guidance is very clear that difficulty breathing, or a loss
of consciousness must be treated as a medical emergency with an urgent
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response. As there are no healthcare staff overnight at the prison, it is even more
critical for operational staff to comply with the emergency procedures. We
recommend:
The Governor should ensure that all staff are fully aware of and understand
their responsibilities in a medical emergency, including the use of an
emergency response code if a prisoner has breathing difficulties, or is
unresponsive.
Funeral and repatriation expenses
39. PSI 64/2011 sets out the processes after a death in custody, including financial
help. Prisons must offer a contribution of up to £3000 towards funeral expenses, as
well as reasonable repatriation costs if the deceased prisoner was a foreign
national.
40. While The Mount paid £2,450 for repatriating Mr Muzhuzha’s body to Zimbabwe,
significantly more than the average cost of £1,200 noted in the PSI, there is no
evidence that they offered anything towards his funeral expenses. As a funeral and
a repatriation incur separate costs, prisons are expected to offer contributions to
both. We recommend:
The Governor should ensure that staff offer reasonable funeral expenses, in
addition to repatriation costs, if a deceased foreign national prisoner is
repatriated.
Prisons and Probation Ombudsman 7
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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