Eshea Nile Dillon 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.
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 did enter the cell Nile had already lost consciousness and was later pronounced dead on 24 March 2018.
Distraught by what had happened and desperate for answers, 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 following the tragedy after the hearing, which concluded last night at Rutland and North Leicestershire Coroner’s Court, highlighted a number of issues in the care that Nile received.
While the jury’s delivered an ‘open conclusion’ conclusion, and the cause of death was unascertained, they did find 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 - this is the alert a prison officer makes on the radio that immediately calls for an ambulance.
- The prison officer in attendance was unaware of their discretion to call a ‘code blue’ without referring with 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.
Known to his family and friends by his middle name, Nile was a young Black man from Hackney. His family describe him as a beautiful boy who loved life. He was adventurous and enjoyed dancing and music.
Speaking following the inquest Aimee Brackfield, a public law expert from Simpson Millar who was acting on behalf of Nile’s 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 officers 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.”
Caroline Finney, a case worker at 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.”
The family has also thanked the charity INQUEST and their lawyers at Simpson Millar for their 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 INQUEST which is calling to introduce automatic, non-means tested legal aid funding for bereaved families following state related deaths.
In his teens Nile became involved with local young men who his family believe groomed him to get involved in criminal and gang activity. However, he worked hard to get out of the problems of the local area, and had trained in travel and tourism and worked as a hotel apprentice and in various other jobs.
Nile was sent to prison in March 2017 for drug offences and initially held in HMP Woodhill. He was transferred to Stocken three months later. At the time of his death Nile was in a single cell.
Nile had asthma since he was a child and had a lung capacity of just 55%. He was prescribed medication, to be administered regularly through a nebuliser or inhaler.
In recent months Nile had missed asthma reviews but two days before his death he had seen a nurse for a review and reported frequent shortness of breath and regular asthma symptoms.
In the past five years (October 2016-21) there have been thirteen deaths in HMP Stocken, including Nile’s. The majority of these relate to physical ill health, and all but one of those who died were under 60 years old. Previous reports from the Prisons and Probation Ombudsman have been critical of emergency responses.
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