Widow Instructs Public Law Experts To Help Establish Answers Following Father-Of-Five’s Death

The devastated family of a Birmingham man who died after being found unresponsive in his prison cell have spoken out following an inquest into his death.

Father-of-five, Saifur Rahman, was taken to hospital in January 2021 after being discovered by prison officers suspended in his cell at HMP Birmingham. Saifur was detained on the healthcare ward of the prison under the care of clinicians at Birmingham and Solihull Mental Health NHS Foundation Trust.  He was diagnosed with a brain injury caused by a lack of oxygen.  He died three days later, aged 39.

An inquest into his death was held at Birmingham Coroner’s Court over ten days, with Saifur’s family represented by public law and human rights experts from Irwin Mitchell and Stephen Clark of Garden Court Chambers.

The inquest concluded that Saifur’s cell should not have been in use as it was unsafe. The inquest heard evidence that there had been many missed opportunities to identify and rectify the faults with the cell but this had not been done. The Coroner determined that, in light of the evidence heard during the inquest, it was necessary for the court to make a Prevention of Future Deaths report which will be sent to the Secretary of State for Justice, the Care Quality Commission and the Chief Coroner for England and Wales.

Expert Opinion

“Saifur’s death continues to have a profound effect on his loved ones, who are understandably still struggling to come to terms with losing him. As a family they had many questions of the prison and NHS Trust about how Saifur came about his death and believe his death was preventable.

While nothing will make up for their loss, we’re pleased to have been able to help provide Saifur’s family with the answers they deserved and support them through this difficult process.

The inquest highlighted serious concerns surrounding the events that led up to Saifur’s death including systemic and operational failings at HMP Birmingham. It’s now vital that HMP Birmingham ensure lessons are learned so that these failings are not repeated in the future.

We’ll continue to support the family as they attempt to come to terms with their loss.”
Alexander Terry - Associate Solicitor

Saifur was remanded in HMP Birmingham on 16 November 2020, and admitted to the health ward late November due to being diagnosed with Mixed State Bipolar Disorder and was put on medication.

On 7 January 2021, Saifur was being considered for a secure psychiatric hospital referral after refusing to take medication and spending several weeks in healthcare.  However, this didn’t go ahead when Saifur’s compliance with his medication improved, the inquest heard.

At 5.01pm on 20 January, two prison officers and a nurse went to Saifur’s cell but were unable to see him or get a response. The custodial manager instructed officers to change into PPE and they entered the cell at 5.13pm.  Saifur was found unresponsive and staff began administering oxygen and CPR.

Paramedics arrived at 5.30pm and Saifur was taken to hospital.

At 1.04am on 23 January, he was pronounced dead, the inquest was told.

The inquest heard that there were failings in relation to the safety of Saifur’s cell, which had been reinstated after several years following damage. The cell contained a ligature risk which had not been properly identified and dealt with appropriately. That ligature point was an unnecessary risk and could have been removed at any time during the three years that the cell was out of use. The inquest heard from several witnesses who did know about the risk, claimed they had reported it appropriately but no action was taken. A wall mounted mirror was also missing, which would have allowed staff to see into his bathroom area and may have led to them finding Saifur earlier.  In addition, a damaged observation window had not been identified as a risk.  Had these deficits in the fabric of the cell been addressed, it may also have allowed staff to see Saifur.

The family were concerned with the mental healthcare Saifur received in prison and whether it was equivalent to that which he could have expected in the community. The clinicians in prison did not consider Saifur to be at risk of self-harm or suicide despite the poor state of his mental health. The inquest heard that staff on the healthcare ward knew very little of Saifur’s history of mental ill health and did not take steps to consult with Saifur’s family. A Prisons and Probation Ombudsman (PPO) report found that therapeutic intervention was minimal and staff also failed to conduct a mental capacity assessment when Saifur refused his medication.

Furthermore, it appeared that not all staff were aware they could enter a cell without meeting the unlock requirement in an emergency situation, and there was a delay calling the medical emergency code.

As a result, recommendations have been made by the PPO for the Head of Prison Healthcare to review of ligature risk assessment policy to determine why the ligature point was not identified, to review the model for delivering therapeutic intervention making it available to all prisoners admitted to the inpatient mental health unit.  Recommendations were also made in relation to record keeping, ensuring staff receive training on the Mental Capacity Act and their responsibilities during emergencies.  Importantly, the PPO recommended that the risk assessment process needed reviewing to ensure all risks are identified, and reinstated cells should not be used until all damage is reported and modifications made.

Prior to his death, Saifur had been married to his wife for 19 years.  The couple had four sons and one daughter.

Following the hearing, Saifur’s wife reported: “Not only was Saifur a wonderful husband but he was also a loving son who has left his mother devastated. No mother should ever have to go through burying their child. His siblings feel lost without the presence of their brother who would always brighten up the room with his smile and humour.

“Saifur was such a hands-on dad who was involved in all the daily activities like school runs, preparing lunches, visits to the park, bike rides and camping nights in the garden on the trampoline with the kids.

“He was normally such a calm and collective person who was really friendly and would easily build rapport with anyone he came across.

“Sadly, his mental health deteriorated.  It was really tough on us all as a family.

“When he went to prison, it turned our lives upside down as this wasn’t the Saifur I knew and loved.  To then be given the devastating news that he had died completely broke me.  For the past year, I’ve had so many questions over what happened to him, and while the inquest has been unbelievably hard, I’m grateful to at least have some answers now.

“Although Saifur is no longer with us, I see him in the smiles of our children.  I have a difficult journey ahead of me as I now have to be their mum and dad, but I’m determined to make sure I can give them enough love for the both of us.

“I just hope that by sharing our story, lessons can be learned to help stop other families from suffering like we have.”

Jodie Anderson, of the charity INQUEST, who supports the family, said: “Three years on since the Ministry of Justice seized urgent control of Birmingham prison from G4S and still nothing changes and lives are needlessly lost. Saifur’s death should never have been allowed to happen and reflects the inhumanity of a system that criminalises people for being mentally ill.  Saifur had been admitted to the inpatient mental health unit of the prison due to concerns over his mental health. Without therapeutic care, he was instead placed into an outdated and unsafe cell with unidentified ligature risks, outdated risk assessment and obstructed visibility inside. The inquest highlighted a catalogue of failings. How many lifesaving recommendations and “lessons learnt” must there be before urgent action is taken to end the use of prison for people in mental health crisis.”

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