Azroy Dawes-Clarke Inquest: Jury finds unnecessary and disproportionate restraint caused death at HMP Elmley

Azroy Dawes-Clarke, a 28 year old Black man, died after ligaturing and subsequently being restrained by staff at HMP Elmley, on 10 November 2021. An inquest jury found that prolonged restraint which was inappropriate and disproportionate contributed to Azroy’s death. The jury found that staff showed a ‘deeply concerning lack of care and compassion towards Azroy’.

Azroy was a semi-professional football player and loving father of four. He loved music and fantasy movies, especially Lord of the Rings and The Lion, The Witch and The Wardrobe. His family describe him as kind-hearted and compassionate and always putting the needs of others before his own.

Azroy had a history of self-harm when he felt unfairly treated or that his needs were not met whilst in prison, although this was not something his family were ever made aware of. He also had several significant physical health conditions that required ongoing treatment.

On 23 April 2020, Azroy was recalled to prison for breaching his licence and was taken to HMP Elmley. From October 2021 onwards, Azroy’s mental health deteriorated rapidly. On 25 October, Azroy was restrained by staff, with CCTV footage showing a prison officer jumping on Azroy’s back and putting her hands around his neck as he walked calmly to his cell.

The Prison and Probation Ombudsman (PPO) stated this incident involved “potentially very dangerous” and unapproved restraint techniques and that there was no evidence to suggest the use of force was reasonable or proportionate.

Following the incident, Azroy was moved to segregation. He was later found having tied a ligature and placed on the suicide and self-harm care planning process known as ‘ACCT’. On 9 November, Azroy barricaded his cell and ligatured again. He told staff that he believed people were trying to get into his cell to kill him, and asked to be moved.

Azroy was moved to the healthcare inpatient unit, where he was placed in a ‘safer cell’ under half hourly observations. At an ACCT review meeting that day, it was agreed Azroy would remain on 30 minute observations.

The next morning, Azroy again told the psychiatrist conducting his assessment that he felt that other prisoners and staff were against him. The psychiatrist assessed that Azroy’s paranoia and risk of suicide or self-harm was elevated and that he should remain in the healthcare inpatient unit.

A prison officer observed Azroy at various points on 10 November talking to himself in his cell, as if he were talking to somebody else. This was not escalated to the mental health team. Staff carrying out observations on Azroy that day had not read his ACCT and were unaware of his mental and physical health conditions.

At 4.40pm, Azroy pressed his cell bell and was found by a healthcare professional who said she saw him having tied a ligature. Two officers were called and entered the cell to remove the ligature. A ‘code blue’ medical emergency was called. At around 4.50pm, two prison GPs observed Azroy was experiencing seizures and administered three doses of diazepam. Paramedics were requested and attended the cell at 5:34pm.

Despite the medical emergency, prison staff made the decision to try to dress Azroy in boxer shorts rather than take him to hospital in the anti-ligature gown. They gave evidence that at this point, Azroy became distressed and ‘agitated’.

At the inquest, the jury heard various accounts of what happened next, some of which said that Azroy was conscious, kicking out and striking officers, others said that Azroy’s movements were involuntary due to the seizures.

The prison officer who instigated the restraint described it in an initial account to the police as like ‘being on a bucking bronco, loud animal noises, really distressing.’ During questioning at the inquest, the officer denied using this animalistic language to justify his actions.

Six prison officers restrained Azroy on the floor of his cell. None of the officers who instigated or were involved in the initial part of the restraint were wearing body-worn cameras. Despite the prison policy requiring healthcare attendance during a restraint, no member of healthcare was present until later on.

Another prison officer involved in the restraint described Azroy as ‘grunting’ with his ‘eyes bulging’. He told the police during their investigation that ‘for some reason I thought of George Floyd and his breathing, [Azroy] was a big unit, I had never felt someone so strong’. Azroy was 5 foot 8 inches tall and weighed just over 15 stone. During cross-examination on his use of racial tropes to describe Azroy, the officer said that this was due to ‘a lack of vocabulary’ on his part.

At 6:07pm, two custodial managers arrived in the cell and activated their body-worn cameras (BWV). This footage, shown at the inquest, showed Azroy lying on the floor on his back being restrained by five officers.

One of the custodial managers could be heard saying she was concerned about Azroy’s breathing and that this could be a medical emergency. Despite this, the other custodial manager, who was casually walking to the scene and heard humming in a jovial manner on his way to the cell emergency, decided that Azroy should be handcuffed.

The officers applied handcuffs to Azroy and he very quickly went limp, either just before or just after the handcuffs were applied. The custodial manager suggested that Azroy could be ‘faking it’ and said if he does not respond to “drop him’, but officers noted that Azroy was unresponsive. At least two officers present – and paramedics outside the cell – were trained in CPR, but no resuscitation efforts were made for a prolonged period, until a nurse working for prison healthcare arrived two minutes after Azroy became unresponsive.

Two healthcare professionals gave evidence that while CPR was being carried out on Azroy, they heard officers outside the cell laughing and joking about Azroy’s genitals.

At 6.53pm, Azroy was taken to hospital where he was pronounced dead shortly after arrival.

The jury found that the unnecessary and disproportionate restraint was causative of Azroy’s death. The medical cause of death was found to be hypoxic ischaemic brain injury due to cardio-respiratory arrest in close temporal proximity to a period of third party restraint shortly after apparent seizure following compression of the neck by a ligature.

The jury also concluded that:

• Azroy did regain consciousness at some stage after the ligature was removed. His level of consciousness varied but he did not deliberately resist staff.
• There was a lack of communication by staff with regards to Azroy’s mental and physical health.
• The restraint was unnecessary and prolonged, inappropriate and disproportionate.
• It was inappropriate for paramedics to authorise the use of handcuffs.
• It was inappropriate for Azroy to be handcuffed at all, and use of them increased his risk of positional asphyxia.
• There was a failure on all parts to communicate effectively and properly.
• Prison officers showed a deeply concerning lack of care and compassion towards Azroy.

Azroy’s sister, Shay Inico, speaking after the conclusion, said: “My brother, Azroy Dawes Clarke, died in the most shocking circumstances – restrained, neglected, and dehumanized while prison staff and paramedics who were trained to save lives stood by and did nothing. Female staff felt too intimidated to challenge male officers. Paramedics themselves were afraid to act because of the power dynamics with prison officers.

After Azroy’s death, we were suddenly presented with two so-called suicide notes – notes that appeared out of nowhere two years later, which we as a family know with absolute certainty are fabricated. Even while I was grieving, officials were quick to suggest he had hanged himself, despite having no clear evidence and without any consideration of his serious medical condition that was ignored throughout his imprisonment.

While he lay vulnerable, undressed, and dying, officers made degrading comments about him – stripping him not just of his dignity but of his very humanity.

This is not just about Azroy. This is about a system that allows people to die avoidably behind closed doors, that fails to protect the vulnerable, that intimidates those who should speak up, and then tries to cover its own failures with lies and blame.

I am speaking out because the public must know that this injustice can happen to anyone’s loved one. We need accountability – not just for my brother, but for every person whose life is put at risk when the prison system and NHS neglect their duty of care.”

Oliver Carter, of Irwin Mitchell, said: “When Azroy died, his mum was told by the prison that he had taken his own life. It was only later that Azroy’s family found out he had been restrained by prison officers for around seven minutes immediately before his death.

Now the jury has confirmed that this restraint – which was described by a trainee paramedic who witnessed it as looking like “a brawl”, with officers on top of Azroy – caused Azroy’s death.

The jury also heard that during the incident with Azroy, one of the officers restraining him thought of George Floyd, a Black man who was killed by a police officer’s knee on his neck. That same prison officer appears in the body-worn footage to have had his knee on Azroy’s chest or torso, in breach of policy and training on the safe use of force. The officer told the court his knee was “hovering” over Azroy.

Many of the healthcare and ambulance service witnesses, and indeed the jury, expressed their condolences to Azroy’s family during the inquest and said how sorry they were for their loss. This was very meaningful to Azroy’s family. However, none of the prison officers expressed any similar sentiments. For Azroy’s family, this reflects the cruelty and indifference shown to Azroy by the prison officers.”

Jodie Anderson, Senior Caseworker at INQUEST, said: “When officers found Azroy in need of urgent medical attention having experienced several traumatic events – ligature, seizure and diazepam – their instinct was not to preserve life but to restrain and control. 

The repeated use of racist, animalistic language to describe Azroy is utterly unacceptable and indicative of wider systemic issues. These harmful stereotypes, which have long been used to justify disproportionate and often fatal use of force against Black men, must be urgently addressed. That one officer even referenced the murder of George Floyd is deeply disturbing.

On the second day of this inquest, an independent report highlighted racial disparities in use of force at HMP Elmley – a stark reminder that what happened to Azroy is not an isolated incident, but part of a broader pattern of institutional racism and neglect in our prisons.”