HIV-positive 21-year-old Thokozani Shiri died in prison after officials neglected him and failed to provide life-saving medication, an inquest has found.

The inquest into Shiri’s death, which took place at Essex Coroners Court, concluded on Wednesday (8 June).

During both periods of time, the prison’s healthcare provider, Essex Partnership University Trust (EPUT), was aware that he was HIV-positive.

However during his first stretch at the prison, Shiri was not seen at an HIV clinic until six days before his release, and was not provided with any antiretroviral medication, a life-saving treatment which suppresses the virus and makes it untransmittable.

During his second stay at HMP Chelmsford, the prison again failed to provide him with the vital medication for months, he was only given it 19 days before he died.

Shiri tragically passed away from an HIV-related infection at Broomfield Hospital on 14 April 2019.

The inquest heard that before his death, Shiri told a prison officer that he “couldn’t breathe” and needed to go to a hospital, but an ambulance was not called until five days later. The prison officer he spoke to has still not been identified.

Shiri’s consultant, who had been treating him outside of prison, told the inquest: “HIV is very treatable. It shouldn’t have happened.”

The jury found that “five separate failings” had caused Shiri’s death, including the failure to provide his medication during both periods of imprisonment, and the failure to refer him to an HIV clinic.

When Shiri was finally taken to hospital, he was put into an induced coma before his mother was able to see him, and remained that way until his death. Despite being in the induced coma, he was kept in handcuffs and chained to his hospital bed.

In a damning report, the Prison and Probation Ombudsman Sue McAllister described Shiri’s care as “unacceptably poor”, and added: “This is a case in which a young man died a preventable death as a result of what I can only describe as neglect by healthcare staff, and whose mother was then treated with gross insensitivity by prison staff.” 

The prison is in the process of completing a list of recommendations laid out in the ombudsman’s report.

Shiri’s family said in a statement provided by law firm Leigh Day: “Thoko was just like any young man – he loved life, his friends and family.

“He was exploring what the world had to offer him, but he ended up on the wrong side of the law, culminating in a short-term custodial sentence. As a family we had great hopes that this would allow him to reflect and look to a brighter future.

“This was not to be, as a short-term prison sentence turned into a death sentence. Thoko was denied very basic care that would have enabled him to live his life despite his long-term condition.

“We are saddened as we know that people with his condition do not have a reduced life expectancy and that, with basic management, his condition was not fatal.”

Deborah Gold, chief executive of National AIDS Trust, added: “Thoko’s death was heartbreaking and completely avoidable. This jury conclusion underlines how many crucial opportunities were missed leading to his entirely preventable death.

“It is shocking that a young man died whilst in the care of the state from a condition that is entirely treatable. Most people with HIV in the UK live long healthy lives.

“It is absolutely essential that all state places of detention including prisons and immigration detention centres, have robust systems in place to identify, treat and support detained people living with HIV.

“It is now incumbent upon all bodies responsible for the care and treatment of prisoners and detainees to ensure this happens. As Thoko’s death shows, failure to do so has devastating consequences.”