The family of a severely asthmatic 22-year-old from Hackney are asking for lessons to be learnt after he was left grasping for breath in a prison cell.
Eshea Nile Dillon, known by family and friends as Nile, died at HMP Stocken in the East Midlands after calling for help inside in his cell and struggling to breathe.
Prison officers did not enter for eight minutes and there was a delay in alerting others to the medical emergency and calling an ambulance.
When officers entered the cell Nile had already lost consciousness and was later pronounced dead on March 24, 2018.
The family sought the help of the charity Inquest, which instructed public law expert Aimee Brackfield from Simpson Millar to act on their behalf at an inquest into his death.
Now, they are calling for lessons to be learnt after the hearing, which concluded on October 22 at Rutland and North Leicestershire Coroner’s Court.
While the jury delivered an "open conclusion" and said the cause of Nile's death was "unascertained", they found that "staff had missed the opportunity to call the ‘code blue’ as soon as it was observed that Nile was struggling to breathe and undoubtedly when he was seen to fall unconscious."
A "code blue" is the alert a prison officer makes on the radio that immediately calls for an ambulance.
The hearing found that the prison officer in attendance was "unaware" that he could call a code blue without referring first to supervisors or that he could enter a cell without fellow officers if, "in his opinion", "there was an immediate risk to life".
The jury added: "From the commencement of CPR until Nile received treatment from the ambulance crew Nile was not given any oxygen."
Nile's family describe him as "a beautiful boy who loved life".
A family spokesperson said: "He was adventurous and enjoyed dancing and music."
The young man's family believe Nile was groomed in his teens leading him to get involved in criminal and gang activity.
They add that despite this he worked hard to overcome the struggles of his youth, and had trained in travel and tourism and worked as a hotel apprentice and in various other jobs.
Nile was sent to prison in 2017 for drug offences. He had suffered from asthmas since he was a child and had a lung capacity of 55 per cent.
He was prescribed medication, to be administered regularly through a nebuliser or inhaler
But in recent months Nile had missed asthma reviews. He saw a nurse two days before his death and reported frequent shortness of breath and regular asthma symptoms.
Following the hearing, the family's lawyer Ms Brackfield said: “As detailed throughout the hearing, there were a number of issues with regards 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."
Caroline Finney, a case worker at the charity Inquest, added: “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.”
Nile's family thanked the charity Inquest and their lawyers at Simpson Millar for representation at the hearing, which they say gave them the "strength" to pursue the answers they "desperately needed".
They are now backing a campaign launched by the charity Inquest which is calling to introduce automatic, non-means tested legal aid funding for bereaved families following state related deaths.
In the past five years (October 2016-21) there have been 13 deaths in HMP Stocken, including Nile’s.
The majority of these relate to physical ill health, and all bar one of those who died were under 60 years old.
Previous reports from the Prisons and Probation Ombudsman have been critical of emergency responses.
A spokesperson for the Prison Service said: “Our deepest sympathies remain with Mr Dillon’s family and friends. We will consider the coroner’s verdict and respond in due course.”
To support Inquest's campaign visit you.38degrees.org.uk/petitions/legal-aid-for-inquests
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