Inmate died after ‘restraint-related' incident in prison, inquest hears
A home office doctor has warned jurors about the 'complex' restraint-related death of a father-of-four prisoner, an inquest heard.
Azroy Dawes-Clarke, 28, from Romford, east London, was an inmate at HMP Elmley, on the Isle of Sheppey, when he died after suffering multiple cardiac arrests on November 10 2021.
He is alleged to have attempted to commit suicide by suffocation before becoming violent and being 'restrained' by prison staff.
The medical cause of death has been given as hypoxic ischemic brain injury but it is unclear when and by whom that injury was caused.
On Wednesday, Home Office forensic pathologist Dr Olaf Biedrzycki told jurors at Kent and Medway Coroner's Court in Maidstone that medically, Mr Dawes-Clarke's case was 'about as difficult as it gets' for him.
He said: 'The cause of death is given as hypoxic ischemic brain injury that's due to either the fact that his heart or lungs stopped working … and that happened very quickly after a period of third-party restraint, which happened shortly after seizure-like activity, which was treated with Diazepam.
'That all followed compression of the neck with a ligature.'
There had been a previous incident where Mr Dawes-Clarke had attempted to self-harm or commit suicide two days before his death, the court heard.
Body-worn camera footage taken in HMP Elmley and shown in court showed four officers kneeling on and next to Mr Dawes-Clarke, who was face down on the floor prior to his first cardiac arrest.
He could be heard yelling repeatedly while restrained, until he was handcuffed and then went limp.
One officer was heard saying, 'Have we got a pulse on him? We're not sure if he's breathing, we're not sure', as Mr Dawes-Clarke lay on the floor.
Medical staff began CPR before he was taken to hospital, he suffered two more cardiac arrests in the ambulance and a fourth upon his arrival at hospital, where he died soon after.
Dr Biedrzycki added that the 'crux' of the inquest would be whether Mr Dawes-Clarke recovered between the suicide attempt and the restraint from prison officers.
'The restraint element is of greater importance if you conclude that the initial ligature compression did not actually cause him to be unconscious and fitting,' he added.
Mr Dawes-Clarke's alleged history of self-harm and suicide attempts whilst in prison was not known to the family; he also had several physical health conditions that required ongoing treatment, the court heard.
His mother, Marcia Neil, was indignant through tears as she told the court: 'Maybe if they'd phoned me, I could have helped!'
Reading a pen portrait, his sister, Shay Inico, said: 'My brother was more than just family; he was my anchor, my confidant, and my unwavering source of support. He was kind-hearted and compassionate, always putting the needs of others before his own.
'Losing him in such a senseless and cruel manner has completely shattered me. The thought of him being restrained, suffering and treated without dignity haunts me every single day.'
Father-of-four Mr Dawes-Clarke liked fantasy films and played semi-professional football, he was in the Arsenal FC academy while he was growing up.
'I share this statement because my brother's story deserves to be heard. He was a person full of love, kindness, and potential. He was not defined by his circumstances, and he deserved so much more than the injustice he faced. His life mattered, and his memory will forever remain in our hearts,' said Ms Inico.
On Wednesday, his mother, sister and uncle were in court to observe proceedings, and his brother appeared via video-link.
Mr Dawes-Clarke was recalled to HMP Elmley on April 23 2020 after breaching his license.
'Where restraint-related deaths do occur, they're invariably erroneously complex cases,' Dr Biedrzycki warned jurors.
He added: 'This is about as difficult as it gets for forensic pathologists, and I don't have all the answers.'
The inquest continues and is listed until July 11.
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