What happened
Azroy Dawes-Clarke, 28, was a father of four. He was recalled to prison for breaching his licence on 23 April 2020. From late October 2021 his mental health deteriorated quickly.
On 25 October 2021 he was restrained. CCTV showed an officer jumping on his back and putting her hands around his neck as he walked calmly to his cell. The Prison and Probation Ombudsman later found the techniques were “potentially very dangerous” and unapproved, with no evidence the force was proportionate.
He was moved to segregation, found with a ligature, and placed on the ACCT care plan. On 9 November he barricaded his cell and ligatured again, saying he believed people were trying to kill him. He was moved to the healthcare inpatient unit on 30 minute observations.
On 10 November at 4.40pm he pressed his cell bell and was found with a ligature. Staff called a code blue and two prison GPs gave three doses of diazepam for seizures. Staff chose to dress him in boxer shorts rather than take him to hospital in the anti-ligature gown, and he became distressed. Six officers restrained him on the floor of his cell. He went limp as handcuffs were applied, and was pronounced dead after arriving at hospital at 6.53pm.
The outcome
The inquest ran at Kent Coroners Court from 18 June to 11 July 2025 before Assistant Coroner Ian Brownhill. The jury concluded that unnecessary and disproportionate restraint caused the death.
The medical cause was hypoxic ischaemic brain injury from a cardio-respiratory arrest close in time to the restraint, after a seizure following compression of the neck.
The jury found that he did not deliberately resist staff, that the restraint was unnecessary and prolonged, that handcuffing him at all was inappropriate, and that handcuffs increased his risk of positional asphyxia. No prosecution or regulatory outcome is recorded.
What went wrong
Officers observing him that day had not read his ACCT and did not know his health conditions. One officer’s observation that he was talking to himself was not escalated to the mental health team. Policy required healthcare attendance at a restraint. No clinician was present until later.
None of the officers who began the restraint wore body-worn cameras, and no resuscitation was attempted for a prolonged period with trained staff present. The jury found a failure to communicate on all parts, and “a deeply concerning lack of care and compassion”.
What it teaches
When a man has ligatured, seized and been sedated, the clinical emergency comes first. Restraint is not treatment, and the person in front of you may not be resisting at all.
Handcuffing a limp man increased his risk of positional asphyxia. Policy required a clinician at the restraint because presence changes what officers do, and no clinician came.
Questions for the room
- He was said to be kicking out; the jury found the movements were involuntary. How would you tell the difference in the moment?
- You have a body-worn camera. When do you switch it on, and what do you say to a colleague who has not?
- An independent report found racial disparities in use of force at the same prison. What would you audit this month?
Evidence and limits
Confidence: probable. The pack holds one source, INQUEST’s press release of 11 July 2025, which reports the jury’s findings. The inquest record itself was not read.
The family’s statements, including their belief that notes produced later were fabricated, are their account, not a finding, and are not repeated as fact here. Proceedings concluded on 11 July 2025, so the page may be cited, but the detail should be completed from the inquest record before it is taught.
The prison’s response is a gap in the source held.
Our vulnerable and volatile persons training covers acute behavioural disturbance, and what to do before hands are used.
Sources
Reviewed 20 October 2026.