Prisoner died after jail staff 'failed to treat his severe asthma'

Exclusive: Reports released to The Independent reveal concerns about serious failings to treat Ashley Gill

A coroner has found serious failings over Ashley Gill's death in prison in April 2015 (Reuters)

A prison inmate who suffered from severe asthma died due to “serious failings” in the way jail staff managed his medical condition, a coroner has ruled.

Senior Coroner Andre Rebello has warned that unless lessons are learned from the death of Ashley Gil, the prison service may experience future fatalities.

Gill, 25, suffered a major asthma attack and died shortly after complaining that prison service staff had removed his inhalers in April last year.

He had been due for release five days after he died.

The father of one had suffered from severe asthma throughout his life.

He was serving a 20-month sentence for theft and was initially at HMP Forest Bank in Salford before being transferred to HMP Liverpool on 1 April 2015.

He had spent time in intensive care due to the condition just days before being transferred.

An inquest at Liverpool Coroner’s Court reportedly heard that prior to his death Gill had made a formal complaint to the prison that staff had taken his inhalers off him after he was transferred.

His complaint, read to the inquest, said: “I have recently come out of intensive care due to my asthma. I came here with all my inhalers but they were taken off me. This is unacceptable due to the level of attacks I have had in prison before and recently coming out of intensive care.”

He was found unresponsive in his cell on 29 April 2015 after suffering an asthma attack and subsequently pronounced dead.

The Independent has now obtained a formal warning letter from the coroner to HMP Forest Bank in which he lists serious failings.

An inquest jury returned a verdict of accidental but Mr Rebello said a series of failures when Gill was transferred between prisons was a contributing factor.

Specifically, the coroner said prison staff neglected to properly record and treat his condition.

Mr Rebello concluded when Gill was transferred: “There was failure to provide initial information regarding care plan and medication. Reception screening was insufficient; based on verbal information received, including lack of follow-up. Asthma treatment was not managed effectively from the 1st April 2015 until 29th April 2015, including insufficient hand over, incomplete assessment, incomplete treatment plan and medication and minimal patient compliance.”

In a Report To Prevent Future Deaths sent to HMP Forest Bank by the coroner, Mr Rebello warned: “In my opinion there is a risk that future deaths will occur unless action is taken… In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action.” He has ordered the prison to ensure they improve systems used to inform prisons of inmates’ health conditions when transferring between prisons.

In a statement issued through charity INQUEST which campaigns on deaths in custody, Gill’s family said: “We are all devastated by the tragic death of Ashley and miss him every day. Ashley was a ‘happy and giddy’ person who had a ‘heart of gold’. He has left behind his young daughter aged just 5 years old. We are pleased that the jury have recognised the criticisms of those who failed to care for Ashley and we hope that steps are taken to ensure that this does not happen again.”

Leanne Dunne, a solicitor representing the family said: “The evidence in this inquest covered numerous failings of basic primary health care. Ashley was not even provided with the medication he had previously been prescribed which the jury heavily criticised and concluded neglect. Ashley made a complaint about his medication and this was still not rectified until the day he died. The Coroner’s expert said it was a “very serious failing” not to provide medication that was essential to treat Ashley’s condition.

The fact that individuals detained by the state are not afforded basic health care is extremely concerning and reflects the crisis in our current prison system.”

A Prison Service spokesperson told The Independent: “Our sympathies are with Ashley Gill's family and friends.

“We will consider the findings of the inquest to see what lessons can be learned in addition to those from the Prisons and Probation Ombudsman's investigation.”