Inmate died after prison staff delayed calling ambulance while he struggled to breathe
A prisoner from Leicester died in his cell after staff failed to call an ambulance. Godfrey Muzhuzha was jailed for life in 2005 after stabbing his wife Judith to death.
Muzhuzha was a Zimbabwean national who was living with his family in Braunstone at the time of the murder. His two young daughters witnessed the attack.
He was incarcerated at HMP The Mount, in Bovington, Hertfordshire, at the time of his death in May 2021. While Muzhuzha died of natural causes, an investigation by the prison ombudsman, which is tasked with looking into any deaths in custody in England and Wales, found failings in the response of staff to him falling unwell.
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A report from acting ombudsman Kimberley Bingham said it was “mandatory” in both national policy and that of the prison itself that the code should be used with “no delay” if a prisoner has breathing difficulties to ensure an ambulance is called “immediately”. However, she added this did not happen when Muzhuzha said he was struggling to breathe. She listed this as a fault in the prison’s response.
Muzhuzha reported feeling unwell on Sunday, May 2, 2021, the report said. He had “a persistent cough, fever and shivering”, with staff suspecting it was Covid-19. He was told to “self-isolate, rest and alert staff if he felt worse”. A Covid test came back as negative later that day, the report added.
The next day, Muzhuzha told officers he felt “alright” at 11.40am and 4pm when his meals were delivered. However, his call bell was pressed at 6.15pm and at that point his cell mate reported he was having difficulty breathing which was confirmed by an officer.
At this point, the emergency code should have been called, the report said.
Muzhuzha was told he would be monitored for 30 minutes, with well-being checks every 15 minutes. If he was no better after that time, an ambulance would be called, he was told. His cell mate was advised to press the bell if they needed help between visits. There were no healthcare staff working at this time.
Around five minutes after officers left the cell, the bell was rung again, the ombudsman report said. Officers returned to find Muzhuzha on the floor “face down, unresponsive, with blood trickling from his nose”. A faint pulse was detected.
At this point, the emergency code was called by an officer for breathing difficulties, with a second code also issued for severe bleeding. The officer told the ombudsman he called both codes “to make it clear that the situation was serious” and said he “also messaged over the radio that an ambulance was required urgently”.
The officers present carried out CPR until paramedics arrived. However, Muzhuzha was pronounced dead at 7.38pm. An autopsy ruled the cause of death was pulmonary thromboembolism - a blocked blood vessel in the lungs - due to deep vein thrombosis.
In her report, Ms Bingham said the staff who went into Muzhuzha's cell "were clearly concerned about his health". However, they did not call a code blue "at that time”.
She added: “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 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.”
She has called on the governor of the prison to ensure “all staff are fully aware of and understand their responsibilities in a medical emergency”.
A contribution of up to £3,000 from the prison to Muzhuzha’s family to go towards his funeral should also have been offered. However, Ms Bingham said this did not happen, though the prison did pay repatriation costs to return his body to Zimbabwe.
Ms Bingham said: “As a funeral and a repatriation incur separate costs, prisons are expected to offer contributions to both.”