Terry and daughter. Copyright: Lee Jasper
There are many more stories of gross injustice than appeared in our mainstream press. Many of the stories affecting black people, racism, and gross injustice fail to get coverage with the mainstream media for many reasons. The case of 54-year-old, black man Anthony "Terry" Roberts from Lewisham, South London is a case in point.
As many of you know, my blog is becoming synonymous with bringing such injustice cases to the broader community's attention and breaking these unheard-of stories into mainstream media.
It is only with your continued support that I can offer this public service platform to those like Terry's grief-stricken partner and surviving daughter who are desperate for the world to know what happened to him.
Terry Roberts father of four died at 4.55 pm Epsom & St Helier University Hospital, Surrey on the 22 April 2018. His subsequent four-week Inquest that culminated on 23 December 2020 with a damming narrative verdict revealed his death's horrific circumstances. The narrative verdict identified "significant missed opportunities" that could have prevented Terry's death by all the agencies involved.
I, along with groups such as Inquest, have long argued that the Inquest process is no longer fit for purpose as a credible vehicle to deliver justice for the victims of those who died in police or prison custody.
The details outlined here were provided to me by Terry's partner of 16 years, Sinéad who doesn't want her surname revealed. She recounted the evidence presented during his Inquest held at Surrey Coroner's Court chaired by Mr D Stuart OBE during November and December 2020.
This is the first time the family have spoken publicly about Terry's death. It's a horrifying story.
Terry was arrested for a minor offence by Lewisham Police on Friday, 20 April 2018. He had underlying illnesses as suffered from chronic obstructive pulmonary disease (COPD) & asthma and had a tracheostomy in 2000. Terry had a surgical hole inserted in his neck to assist with his breathing. After being arrested and detained overnight, he appeared before a magistrate court on Saturday 21 April. And despite being arrested for a minor offence was remanded into custody to Highdown Prison Surrey.
The next day, Sunday morning 22 April 2018 Terry had an exacerbation of COPD and had real difficulty breathing.
A prison nurse called a medical emergency code blue at 11:15 am. This prison code indicates the need for urgent ambulance assistance in response to cases where there are severe and acute concerns about a prisoner's health.
Terry was struggling to breathe and trying to stay alive. Unbelievably, this critical code blue alert was then stood down by the senior prison nurse in Highdown Prison, and the ambulance turned back.
Sinéad told me "This nurse didn't check oxygen sats levels. She should have given Terry nebulisers back to back whilst waiting on the paramedics instead of turning down an ambulance and placing Terry in a single cell to accommodate her lunch break.".
Terry was left alone in a single cell and struggling to breathe wasn't checked by the prison nurse nor prison officers during this time. The senior nurse appeared to be more interested taking her lunch break than Terry's welfare.
When the prison officers did open his cell after lunch, Terry fell out the cell desperately gasping for breath.
Prison officers immediately radioed the senior prison nurse. Despite his desperate condition, she insisted that they escort Terry to her office. Struggling to breathe or walk, barely able to stand, prison officers nevertheless attempted to walk Terry to the nurse.
It just wasn't possible, and as Terry struggled to walk up a flight of stairs and seeing his acute difficulty, Prison staff were forced to walk him back to this cell.
The senior nurse was informed and hurriedly rushed to his cell. Once there, she could see his distressed condition; however, the Prison Nebuliser machine was on another prison wing. The nurse had to radio to get the device to Terry's cell, causing further delays. Shockingly, there aren't Nebuliser's on each prison wing along with defibrillators and other emergency equipment.
As Terry's condition deteriorated, another radio emergency code blue was called at 2.13 pm. This time the prison didn't turn the ambulance back. When Paramedics arrived, they were shocked and alarmed at Terry's critical condition.
He was placed in an ambulance wheelchair and taken to a waiting ambulance still struggling to breathe needing an oxygen mask on his face.
He was escorted by two prison officers who sat in the back of the ambulance. Both handed in their prison radios before getting inside, but both had prison mobile phones, a fact which will become important later.
Terry was undoubtedly a low-risk prisoner according to his risk assessment. Despite this and the fact he couldn't breathe stand or walk, prison guard Oji Asaji Thompson was told by Alison Acton Prison custodial manager to 'cuff him' and put him in chains. Given Terry's condition, this decision is utterly inexplicable.
With Terry's condition deteriorating fast the ambulance was kept waiting in the prison yard whilst the prison governor and her senior staff delayed providing approval for it to leave. That delay was to prove tragically costly.
Such was the delay that both accompanying paramedics, on two separate occasions, jumped out the back of the ambulance asking prison staff what the delay was?
The response of prison officer in the prison car park, Johnathan Hart was "I've already radioed through once'. He left the prison after Terry died and now works for British transport police.
Paramedics gave him more medication in the ambulance, still very concerned about why the prison gates were not opening. Terry was deteriorating with no improvement despite them administering oxygen and medication. Such was the paramedic's concern they made a formal complaint about the prison and Epsom & St Helier University Hospital Surrey Accident and Emergency staff. As the Inquest conformed a series of critical failures and delays led to Terry's untimely death.
In the back of the ambulance, Highland prison officer Rosanne Barbara Slater was chained to Terry. Despite the paramedics' apparent urgency and concern, she and Thompson took no action to open the prison gates in response to the crisis unfolding before them.
Meanwhile, while Terry continued to deteriorate prison staff were letting vehicles in and out of the prison gate,
Sinéad told me "While vehicles were coming and going in out of the prison gates, the ambulance that my loved one was dying in wasn't allowed to leave because of unnecessary paperwork."
After almost 15 minutes of seeing the ambulance driving around a prison car park with blue lights flashing, they were finally allowed to leave.
She added, "Oji Asgi Thompson had a prison mobile phone in his pocket. He didn't use this to quicken things up. He had a set of keys in his pockets also, and didn't use his initiative to call for help, didn't jump out of the ambulance at any time to quicken things up. Didn't unlock the heavy cuffs and chains, instead sat in the back of the ambulance and watched my love one die. Roseanne Barbara Slater did the same. In court she said,
"I was looking at my watch a lot as it seemed a long time we were driving I could see he was in distress I was wondering what was going on'… but she too did absolutely nothing."
The fact that the initial ambulance was turned away by the prison nurse and the second ambulance was unnecessarily delayed undoubtedly cost Terry his life.
They eventually arrived at Epsom & St Helier University Hospital Surrey after a high-speed dash at approximately 4 pm. Terry was ultimately transferred from the ambulance to a Resus bed. In the transfer from ambulance to the hospital bed, the chains became entangled around his ankles and the bed's frame.
It was at that point that Terry's head fell forward and he went into cardiac arrest.
An A&E nurse from Epsom & St Helier University Hospital asked prison officer Roseanne Barbara Slater to remove the cuffs and chains. In a response that defies belief, Slater refused to remove them.
This unnamed Resus nurse outraged at the callous treatment punched and pushed Roseann Slater, calling her a heartless bitch. Slater would later recount this incident at the Inquest as she gave her evidence.
Sinéad has appealed for this nurse to come forward as the Coroner, unbelievably did not see the 'relevance' of the nurse's testimony despite the family barrister demanding a new hearing as this critical evidence had not been disclosed before the Inquest.
"It is vitally important that this brave nurse comes forward. Firstly, we want to thank her for her interventions, and secondly, it is important we hear her testimony if we are to hold those responsible for the death of my partner to proper account".
Terry was briefly resuscitated by chest compressions only as he was still cuffed and chained.
His restraints were eventually removed when Oji Asgi Thompson finally got through to the prison on his prison mobile phone.
Terry sadly died at 4.55 pm due to the callous and brutal treatment he endured in his final hours of life.
Surrey Police were called to Epsom & St Helier University Hospital following Terry's death, but officers failed to take any witness statements,
The Inquest was a joke an insult to justice. The Coroner was appalling; his institutional bias was apparent in his every decision. He refused to allow critical evidence to be heard, he denied due process, and ultimately directed the jury to exclude unlawful killing, corporate manslaughter or negligence. He also refused to allow CCTV from the prison guards, or the hospital to be shown to the jury. He refused to call the brave Resus nurse who tried to intervene.
This decrepit and discredited system of accountability is rotten to its core and all too often subjects the victim's families to the abusive state's full power. It is incapable of delivering justice and represents one of the most outmoded institutions within the British criminal justice system.
It is incapable of reform. If we are to get anywhere close to achieving justice, we need to give life to the mantra Black Lives Matter and demand the Inquest process is radically rebuilt from the ground up.
Describing the subsequent Inquest, Sinéad said,
"Lies corruption and coverups from start to finish as well as the blame game throughout our 4-week Inquest. Terry was a devoted father to our young daughter. She is a Daddy's girl who's had to have bereavement counselling every week since her father's death. After witnessing her father's appalling treatment at the state's hands, she is now experiencing post-traumatic stress disorder, deep trauma and inconsolable grief.
Terry was my soul mate, my confidant, my advisor, my best friend, my loving partner. I am devastated. He died with no dignity & respect & no family around him. I am determined to get justice for Terry."
We are demanding a full public enquiry into the preventable death of my loved one. The Coroner's decision to exclude evidence in a direction given to the question very makes no sense given the evidence presented during the hearing.
We are desperately urging the public to support our demand by signing our public petition.
We also want the public to highlight and share this horrific story. We don't want Terry to have died in vain. We wish to ensure those responsible are held to account, and other families are spared the tragedy and the horror what happened Terry."
Terry was one of 7 who lost their lives at Highdown prison Surrey during 2018.
There have been 1827 deaths in prison in England this past five years, that's 1827 deaths too many, and just like Terry, that's 1827 stories that people don't hear about.
There have been no successful prosecutions against any officers involved in suspicious death in police or prison custody. None.
