Jury identified serious failures by G4s at the inquest into the death of Mohamoud Ahmed Ali

37-year-old Mohamoud died on 1 February 2014 in HMP Parc – a prison run by G4S. He died from ‘SUDEP’ (‘sudden unexpected death from epilepsy’). Despite having suffered several episodes of apparent seizures in December 2012, January 2013, and April 2013, he was never diagnosed with epilepsy. Although Mohamoud had been referred to hospital for assessment by specialist neurologists, the jury found that the prison repeatedly failed to transport him to appointments in May, June, and July, due to a lack of G4S staff to escort him there.

The jury found that there was a failure to recognise ongoing risks to Mohamoud in the process whereby multiple medical appointments were made, and then cancelled. Even after he did make it to a hospital appointment in August 2013, no diagnosis was made. The court heard that although Mohamoud was reticent about talking about his seizures, this was not uncommon among epilepsy sufferers. The jury found that medical professionals were unaware of the information held by the prison about his condition as it did not travel with him to the appointments. The jury went on to find that, if all of the information had been available to specialists, it was probable that a diagnosis would have been made earlier. The inquest heard evidence from epilepsy expert Professor Matthias Koepp that, as early as January 2013, there was enough information in the prison records for a specialist to diagnose epilepsy, and that Mohamoud exhibited all risk factors. It was a serious failure, he said, that the prison had failed to communicate the information held about Mohamoud’s symptoms to the medical specialists.

Yet another hospital appointment was cancelled by G4S because of a lack of escorts. Mohamoud was eventually taken to an appointment with another specialist in December 2013. However, yet again the prison failed to convey information about Mohamoud’s symptoms to the consultant who – in her evidence before the court – stated that she would have diagnosed epilepsy if she had received the relevant information. Not only was she unaware of key details of the seizures that Mohamoud had suffered in prison, she was also not told about his previous appointment in August.

The jury found that G4S had failed to provide adequate, up to date information to the medical specialists with whom Mohamoud had appointments. The jury went on to find that within the prison healthcare department, information sharing was inconsistent and varied, and moreover, that knowledge sharing between prison staff was inadequate. The Coroner noted Professor Koepp’s opinion that the prison had accumulated information that would be of immense assistance to an epilepsy expert – indeed, that be would have been decisive in making a diagnosis, but that it was a serious failure not to convey that information those records to the expert neurologists to whom Mohamoud had been referred.

The court also heard evidence from Professor Koepp as to the ever-present dangers of SUDEP to epilepsy sufferers, and the dramatic increase in that risk if they sleep alone. At the time of his death, Mohamoud was detained in a single occupancy cell. The jury found a possible failure by the prison authorities to consider medical input in cell sharing risk assessments.

After the jury returned their conclusions, the Coroner noted his intention to issue a report with recommendations aiming to prevent future deaths, which will be sent to G4S at HMP Parc, as well as to Healthcare Inspectorate Wales and the Chief Coroner.

Holima Warsama, mother of Mohamoud, said:

I can’t bring my son back, but for people in the same boat, dealing with the same company, G4S, I want to make people aware of what can happen to people in prison in immigration detention. Unlike the vast majority of prisoners at HMP Parc, who were serving criminal sentences, in administrative detention Mohamoud was living with the uncertainty of not knowing how long he would be there, or even really understanding why he was there.

I don’t want other people to have to grieve and to have to go through an inquest. One of the most upsetting things is that the information sharing about Mohamoud’s epilepsy failed to get to the specialists, who needed that information, to give him proper care.

Deborah Coles, co-director of  INQUEST said:

This inquest has found unacceptable failures of medical care in a G4s ran private prison.  This is not an isolated case, and indicates failure to act on previous recommendations.  How many more deaths need to take place before there is decisive action to deal with issues such as basic information sharing?

INQUEST has been working with the family of Mohamoud since February 2014. The family is represented by INQUEST Lawyers Group members Matt Foot of Birnberg Peirce and Partners and Paul Clark of  Garden Court Chambers.

Paul Clark is a member of Garden Court Chambers' Inquests Team.