A family wants lessons to be learned after their asthmatic son died in his prison cell after he began to struggle with his breathing.
22-year-old Eshea Nile Dillon, a long-term asthma sufferer, was alone in his jail cell on the evening of his death in March 2018.
Known to his family and friends as Nile, he fell unconscious and was experiencing fits before officers entered his cell at HMP Stocken, in Rutland, reports Leicestershire Live.
He was later pronounced dead.
An inquest into his death has heard that prison officers did not enter his cell for eight minutes and there was a delay in alerting emergency services.
His family, who described him as "a beautiful boy who loved life" say they have been left distraught and desperate for answers.
The inquest, heard at County Hall in Glenfield between October 18 and 22 this year, concluded the cause of his death was 'unascertained' but said the case raised a number of issues about the care he had received.
However, even if officers had reacted quicker, it is 'unlikely' his life could have been saved, the inquest concluded.
The inquest heard the emergency call bell was pressed in Nile's cell at 5.32pm on the day of the tragedy, March 24, 2018.
An emergency 'code blue' - an alert made by prison officers via radio to call for an ambulance - was made eight minutes later.
The inquest heard that there was an opportunity to call the 'code blue' as soon as officers saw that Nile was struggling to breathe and "undoubtedly when he was seen to fall unconscious".
Although prison officers have the discretion to call a 'code blue' without having to first refer to supervisors, the officer in attendance was unaware of this. He did not exercise this discretion.
He was also unaware of prison officers' discretion to enter a cell without fellow officers if, in his opinion, there was an immediate risk.
While in his cell, Nile slumped to the floor from his bed and was seen to fit.
Between the time he was given CPR and the arrival of an ambulance crew, Nile was not given any oxygen.
The inquest heard that in this instance, the delay in raising a 'code blue' alert and delay to the commencement of CPR did not affect the outcome for Nile.
But the hearing has raised concerns about the training HMP Stocken staff received and the family now hope avoidable tragedies can be prevented in the future.
Due to Nile's condition, which left him with a lung capacity of just 55 per cent, he was prescribed medication to be regularly administered through a nebuliser or inhaler.
In recent months prior to his death, Nile had missed asthma reviews but was seen by a nurse for a review two days before he died that reported frequent shortness of breath and regular asthma symptoms.
Aimee Brackfield, of law firm Simpson Millar and who was acting on behalf of the family at the hearing, said: "As detailed throughout the hearing, there were a number of issues with regards to the care that Nile received that raise important questions about the training that HMP Stocken staff received.
"While the family accept that had the prison offers acted sooner to call for emergency medical support it is unlikely to have changed the outcome, it is their hope that lessons will be learnt in order to prevent any future, avoidable tragedies.
"The family are very grateful to the coroner and the jury for their time throughout the hearing, and to have the answers to some of the many questions that they have had since Nile passed away in 2018."
Nile's family said he was "adventurous and enjoyed dancing and music".
They believe that during his teens, Nile was groomed into criminal and gang activity by young locals he became involved with in the area of Hackney, London, where he lived.
Despite this, they say he worked hard to escape the problems in the local area and went on to train in the travel and tourism sector, working as a hotel apprentice and various other jobs.
In March 2017, he was sent to prison for drug offences and initially held in HMP Woodhill before being transferred to Stocken three months later.
Nile's family has received advice and support from campaigning charity, Inquest.
Caroline Finney, a caseworker at Inquest, said: "It is genuinely shocking that in 2021 a young man in his early twenties, who was known to have asthma, could be left struggling to breathe in his cell while prison staff waited ‘for permission’ to call for an ambulance.
"Clearly changes need to be made to ensure this never happens again."
A Prison Service spokesperson said: "Our deepest sympathies remain with Mr Dillon’s family and friends. We will consider the coroner’s verdict and respond in due course."
A report by the Prison and Probation Ombudsman is pending.
Practice Plus Group have also been contacted, which is responsible for healthcare in the prison.
A Practice Plus Group spokesperson said: "We would like to extend our condolences to the family of Mr Dillon at what we know is an exceptionally difficult time.
"Shortly before his death Mr Dillon was seen in the asthma clinic and was given training on the optimal way to use his inhalers.
"As the coroner heard, the independent NHS clinical review concluded that the healthcare Mr Dillon received at HMP Stocken was equivalent to that which he could have expected in the community and the treatment for his asthma and eczema was good.
"However, we continue to review and improve policies and protocols following any death in custody and we have implemented appointment audits and a ‘did not attend policy’ which catches patients that frequently do not attend healthcare appointments to ensure these are rescheduled and patients are seen."
Following the hearing, Nile's family thanked Inquest and their lawyers, for giving them 'the strength to pursue the answers they desperately needed' and are now backing a campaign to call for automatic, non-means-tested legal aid for bereaved families following 'state-related' deaths.
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