What happened
Godfrey Moyo, 25, was on remand at HMP Belmarsh. At about 02:50 on 3 January 2005 he suffered an epileptic fit in his cell.
Officers went to the cell with a nurse. On regaining consciousness he was in a postictal state and attacked a cellmate. Five officers entered and a vigorous struggle followed, in which three were injured. They brought him to the floor on the landing outside the cell.
The inquest jury found that full control was achieved immediately, and that he was then restrained face down for approximately 30 minutes. During that time he suffered at least two further fits, followed by periods of unconsciousness in which his breathing was restricted by his position.
He was lifted, carried to the health care centre, and placed in an intensive care cell kneeling against the bed with his head on the mattress, still restrained. He died there between 03:30 and 03:50.
The outcome
The inquest before HM Deputy Coroner Andrew Walker concluded on 6 July 2009. The cause of death was positional asphyxia with left ventricular failure following restraint, and epilepsy.
In a narrative verdict the jury found that restraint and neglect caused the death. The first nurse failed to monitor him adequately, contributing by neglect; the second failed to monitor him in the intensive care cell, directly contributing.
The ambulance was called at 04:45, about an hour after he was placed in that cell. No criminal proceedings are recorded in the sources held.
What went wrong
The struggle was over in seconds and the restraint went on for half an hour. At no point, the jury found, did anyone attempt to move him off his front, as the control and restraint guidelines required, or put him in the recovery position.
Officers said in evidence that they could not recognise the trigger signs of positional asphyxia, despite their training. The signs were taught, and they were not seen.
The clinical response also failed. The two nurses did not speak to each other across roughly an hour and a half. A trolley was available and not used, and he was not given rectal diazepam.
He had fits at Belmarsh in July and October 2004, with no care plan and no risk assessment for postictal violence. The night staff met a known pattern as a surprise.
What it teaches
Once control is achieved, the risk moves from the struggle to the position. A prone hold maintained after a person stops resisting is the danger, and those watching for breathing are as much part of the intervention as those holding.
Epilepsy is a restraint risk factor, not a separate medical matter. A man who has just had a fit, and may have more, needed a plan before anyone put a hand on him.
Questions for the room
- Control was achieved immediately and the hold continued for 30 minutes. What was it for?
- He had two fits in the previous six months. What should have been in the care plan, and who should have read it before that night?
- The first nurse raised concerns about monitoring and they were not acted on. What does a concern have to become before someone acts?
Evidence and limits
Confidence: probable. The jury’s narrative is quoted in full by INQUEST, which is the one source opened. The solicitors’ case note that would corroborate it returned an error and was not read.
The deputy coroner said he would make a rule 43 report to ministers, and described a “complete lack of understanding of epilepsy among the staff including medical staff”.
The trolley, the diazepam and the earlier fits are recorded as evidence heard at the inquest, not as findings of the jury. No member of staff is named.
Our vulnerable and volatile persons training covers acute behavioural disturbance, including the presentations that follow a seizure.
Sources
Reviewed 20 October 2026.