Footage shows prison officers laughing moments before restrained inmate's death
Azroy Dawes-Clarke, 28, from Romford, east London, was an inmate at HMP Elmley on the Isle of Sheppey, Kent, when he died after suffering multiple cardiac arrests on November 10 2021.
He had tied a ligature around his neck before officers intervened and began a restraint which 'escalated unnecessarily', jurors concluded by majority at Kent and Medway Coroners Court in Maidstone.
In the record of inquest, jurors also found that officers showed a 'deeply concerning lack of care and compassion' during the incident.
The bodyworn footage, released to the PA news agency, shows officers joking about the size of the handcuffs they needed for Mr Dawes-Clarke while he groaned on the floor.
The inquest revealed the handcuffs were wrongly applied to Mr Dawes-Clarke during the restraint, and may have also played a part in his death.
In the footage the officer wearing the camera is heard singing as he fetches the cuffs before choosing a different set and saying 'no not that one, that might give him a little too much freedom'.
Jurors found: 'It was inappropriate for the paramedics to approve the handcuffing of Mr Dawes-Clarke having had no training in mechanical restraint to give such advice.
'Following on from this, it was inappropriate for Mr Dawes-Clarke to be handcuffed at all, especially with regard to his positioning and positional asphyxia.'
They added that there were 'significant shortcomings from both the paramedics and prison officers' in response to Mr Dawes-Clarke going limp and that 'leadership was lacking' throughout the restraint.
The medical cause of death was given as hypoxic ischaemic brain injury but jurors had to determine when and by whom that injury was caused.
'Throughout the restraint, the proximity of a prison officer's knee to Mr Dawes-Clarke's chest was bad practice. On top of this, leadership throughout the restraint was lacking and control of Mr Dawes-Clarke's head was not prioritised,' The inquest found.
In their record of inquest, jurors noted the initial self-ligature, the subsequent restraint, the 'poor practice' handcuffing, failing to consider Mr Dawes-Clarke's head position and 'insufficient' action taken upon realising the cardiac arrest as part of a combination of factors which led to his death.
At one point, the bodycam wearer asks 'who's actually doing the head position on this restrain here then' to a non-plussed response from the restraining officers.
When the footage cuts off, medical staff began CPR on Mr Dawes-Clarke before he was taken to hospital, he suffered two more cardiac arrests in the ambulance and a fourth on his arrival at hospital, where he died soon after.
The officer who initiated that restraint, Alexander Shaxted, denied using 'animalistic' language to describe Mr Dawes-Clarke in order to justify his choices while giving evidence.
Jurors heard that Mr Shaxted had said in his police statement that Mr Dawes-Clarke was making 'loud animal noises' and again referenced it during the Prisons and Probation Ombudsman (PPO) investigation.
'Four times you described him like an animal, animalistic, like a bucking bronco,' said Allison Munroe KC, on behalf of the family.
The officer said that he did not know why he had used those words at the time.
Jurors found: 'There is a lack of justification to suggest de-escalation of the restraint of Mr Dawes-Clarke was attempted.
'Alongside this, the inappropriate comments made by prison staff about Mr Dawes-Clarke portray a deeply concerning lack of care and compassion towards Mr Dawes-Clarke.
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.
He was recalled to HMP Elmley on April 23 2020 after breaching his licence.
After the inquest concluded, his sister, Shay Inico, said: 'My brother, Azroy Dawes-Clarke, died in the most shocking circumstances, restrained, neglected, and dehumanised 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.
She added that this case was not just about her brother, but 'a system that allows people to die avoidably behind closed doors' and accused the prison of covering up its failures.
Assistant coroner for Kent Ian Brownhill has commissioned three separate prevention of future deaths reports as a result of this case.
After the inquest, a Prison Service spokesperson said: 'Our thoughts remain with the family and friends of Azroy Dawes-Clarke.
'Since this incident, we have taken action to improve staff training around use of force, and we will now carefully consider the inquest's findings in full.'

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