Immigration officers who chased an asylum seeker before he fell through a roof could have contributed to his death, an inquest jury has found.
Mustafa Dawood suffered fatal head injuries after falling through the plastic roofing of Shaftesbury hand car wash in Newport.
The 23-year-old had fled persecution in his home country of Sudan but had his asylum claim refused by the Home Office, the inquest heard.
When officers carried out an enforcement visit on the morning of 30 June 2018, Mr Dawood mistakenly thought he would be arrested and fled, climbing on to pallets and through a metal door before accessing the roof.
It took the jury under three hours to decide the actions of officers during and after the pursuit was called off could have contributed to Mr Dawood’s death.
Addressing Newport Coroner’s Court, the jury foreperson said: “During the pursuit, Mustafa started to climb and it was determined the pursuit should be abandoned.
“Nonetheless officers remained relatively close and did not withdraw to a distance away from him. We consider that maintaining the proximity could have contributed to Mustafa’s death.
“We consider the decision to abandon the pursuit was not effectively communicated to all officers and that this could have been a contributory factor to Mustafa’s death.
“The decision for an officer to keep his baton in a racked position could have possibly contributed to Mustafa’s death.”
They added: “The officers were not appropriately trained in pursuit procedures and this could have contributed to Mustafa’s death.”
Coroner Caroline Saunders said that while the Home Office had made changes in the wake of Mr Dawood’s death, she would be writing a recommendation for improvements to be made in the training of officers in pursuit procedures.
Turning to Mr Dawood’s mother, Hameda Hamed Shogar Ahmed, who has been present in court throughout the inquest, Ms Saunders said: “No one in court this week can have been unmoved by the problems Mustafa faced in Sudan and the events of the 30 June 2018.
“You’ve shown such courage in coming to the UK and attending a foreign court where you’ve had to relive these events.
'He was just a young person asking for safety'
“If I may say, on a personal note, I’ve been humbled by the patient, gracious way you’ve sat through this inquest.
“Please accept my sincere condolences,” she added.
The jury heard how Mr Dawood had fled from ‘ethnic cleansing’ against the Zaghawa tribe in which he belonged.
During the five-day inquest Ms Ahmed described how her son had found himself in increasing danger and decided to leave, fleeing to the UK in 2015.
She said: “(In Sudan) there is so much killing every day, so many young people are killed or disappeared – that’s why our young men have to flee to avoid the same destiny.
“My son was not a thief or a murderer, he was just a young person asking for safety.”
Matthew Day, the officer in charge on the day of Mr Daywood's death, had told the inquest he called off the pursuit due to safety concerns, but jurors heard other officers say they don’t recall the order to stop.
In a statement released after the inquest, Ms Ahmed said: “By listening to the testimonies of the witnesses, several facts became apparent to us. The immigration officers were not well trained, and if they had been this disaster would have not occurred.
“Also the officers made serious mistakes when pursuing Mustafa – they did not move away from him after they decided to terminate the pursuit: in fact one officer pulled out his baton in an aggressive manner and Mustafa then climbed onto the roof from which he ultimately fell to his death.
“The family wish to acknowledge the efforts the officers went to when attempting to save Mustafa’s life after he fell,” she added.
“It is also important that the Home Office confirmed in the hearing that Mustafa would not have been arrested or removed from the UK if he was caught. We know that his asylum support money had been stopped improperly shortly before her incident and we believe that is why he was working at the car wash.
“No matter what we do, Mustafa will not return to life but I would like to say that like this tragedy will not happen to other families. I hope lessons will be learnt from Mustafa’s death.
“I loved my son very much.”
A spokesperson for Bhatt Murphy Solicitors, who were representing the family, said: “Mustafa’s family are devastated and shocked: they thought Mustafa would be safe in the UK, and cannot understand why the Home Office treated him as they did.
“It is a matter of national shame that, as part of the renamed ‘compliant environment’ the Home Office continues to irresponsibly and dangerously pursue vulnerable people during enforcement visits which, as Mustafa’s case shows, has devastating consequences.
“The Home Office needs to urgently review its policies and practices in light of this tragic incident, and to prevent further deaths in the future.”
Catrin Evans, Independent Office of Police Conduct (IOPC) director, said: “It is desperately sad that a young man who fled his own country to seek safety here in the UK died in such awful circumstances.
“I recognise his untimely death has had a profound effect on his family and friends, the Sudanese community here and beyond, and all those who were involved and witnessed the tragic event. I again send Mustafa Dawood’s family my heartfelt condolences at this difficult time.”
Ms Evans said the investigation found the officers involved could not have “reasonably foreseen” the tragic outcome of events.
However, the IOPC made a number of recommendations including that enforcement visits should be tailored, written risk assessments, officers should have greater support and direction, and that squad cars should carry first-aid kits.
The body has also recommended Immigration Enforcement considers using body-worn video cameras and records its radio transmissions.
A Home Office spokesperson said: "This was a tragic incident and our thoughts and condolences are with the family and friends of Mr Dawood.
“We’ve made a number of improvements to our practices following the incident but will carefully consider the findings from the inquest and any further recommendations by the coroner to see what lessons can be learned.”