Inquest into the death of Eshea Nile Dillon

Nile was just 22 when he died at HMP Stocken in the East Midlands. He had severe asthma and had called for help as he was locked in his cell and struggling to breathe. There was an 8-minute delay in providing an emergency response.

The medical cause of Nile’s death was unascertained and the jury delivered an open conclusion, finding that:

·      Staff had missed the opportunity to call the emergency ‘code blue’ as soon as it was observed that Nile was struggling to breathe and undoubtedly when he was seen to fall unconscious

·      The prison officer in attendance was unaware of their discretion to call a ‘code blue’ without referring to supervisors. He did not exercise this discretion.

·      The prison officer in attendance was unaware of their discretion to enter a cell without fellow officers if, in his opinion, there was an immediate risk to life. He did not exercise this discretion.

·      From the commencement of CPR until Nile received treatment from the ambulance crew Nile was not given any oxygen.

During the course of evidence on ‘Preventing Future Deaths’, the Prison confirmed that new ‘spot checks’ had been instigated during night patrol states where Supervisors would visit prison officers on duty and remind them of their training in respect of Code Blue and Cell Entry procedures. The prison appeared to accept that it was reasonable that such spot checks should also be undertaken during the ‘patrol state’ shift (which is the shift which was in place when Nile first called for help).

HMAC Tanyka Rawden indicated that the Prison would have 56 days to confirm whether the practice of spot checks would be expanded in this manner, and if not, to provide ‘good reasons’ for a decision not to implement that change. A Regulation 28 report may be considered at that juncture depending on the outcome of that correspondence.

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