Prison bosses have attempted to explain the mystery of why wardens told an inquest into an inmate's death they had not signed a key document about him - even though the paperwork contained their signatures.
Samantha Goward raised "serious concerns" about the evidence heard at the hearing into the death of 32-year-old prisoner Mohammed Azizi.
The Norwich Prison inmate, who had Crohn's Disease, died in May last year after he refused food, saying it was making him unwell.
But his inquest heard evidence from two officers at the prison, who said a document about Mr Azizi's care - submitted by the prison service as evidence - had not been signed by them, even though it appeared to contain their signatures.
Norfolk Coroner's Court also heard another officer had been asked to add notes to the Assessment, Care in Custody and Teamwork (ACCT) plan after it was supposed to have been completed.
An ACCT plan is produced for prisoners identified as being at risk of suicide or self-harm.
Mrs Goward said in the case of Mr Azizi - who had been jailed for arson - suicide and self-harm had ultimately not been factors in his death.
But she said she was concerned about what had happened with those documents, given how important they could be in other cases.
She said: "If hampered by the lack of full disclosure, there is a risk the full picture is not received and any findings, conclusions and lessons might not address full concerns.”
She submitted a Prevention of Future Deaths report to the governor of Norwich Prison, Her Majesty's Prisons and Probations Service.
Following this, an inquiry was carried out by Norwich Prison, which addressed the mystery.
The report said: “Our enquiry found that there were in fact two ACCT documents opened for Mr Azizi.
“It is clear that the rationale behind this was that staff genuinely believed that the original document had been misplaced.
“The process for opening a duplicate ACCT was poor and did not clearly evidence why this had taken place.
“The original ACCT document was not reported as a data loss, there is concerns that this potentially could happen again without necessary action.
“The presence of two ACCT documents in no way contributed to Mr Azizi’s death but the disclosure of documentation and process was not acceptable.”
It included recommendations for the staff involved to receive advice and guidance, and added that all other prisons in the region would be written to remind them of their responsibilities in supplying documentation when requested.
The report also stated that this appeared to be an isolated case and concluded that the care Mr Azizi received while at Norwich was of a ‘very good standard’ and was equivalent to that which he could have expected to receive in the community.
"He always tried to bring fun and joy to our lives. We miss him dearly and we will always keep his memory alive.”
The inquest jury concluded Mr Azizi died of cardiac atrophy, linked to malnutrition, Crohn’s disease and self-neglect.
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