Ashley Gill suffered from chronic brittle asthma, which he had since he was a child. He was 25 years old when he suffered a serious asthma attack in HMP Liverpool which resulted in his death on 29 April 2016. He was due to be released in just a few days.

The jury, hearing 7 days of evidence in relation to the circumstances leading to his death, heard that healthcare staff at HMP Forest Bank failed to transfer information relating to Ashley’s asthma and prescribed medication when he was transferred to HMP Liverpool on 1 April 2015.

Ashley did not receive a secondary health screening after arriving at HMP Liverpool and was not assigned a chronic disease manager due to staff shortages at the prison. He was noted on several occasions to be concerned about the absence of his medication, which had not been prescribed since he was transferred.

On 16 April 2015, he formally raised a complaint about not receiving his medication which the prison failed to address. Ashley never received his full medication whilst at HMP Liverpool, which an asthma expert described as a ‘very serious failure.’

On the day of his death, the jury heard that a prison GP failed to follow the national guidelines for treating asthma exacerbations during a consultation. Shortly after, Ashley was discovered in his cell suffering an acute asthma attack, before eventually collapsing and suffering a cardiac arrest.

Concluding the inquest the jury recorded that:

• Failure [by HMP Forest Bank] to provide initial information regarding care plan and medication
• Lack of follow-up to reception health screening
• Asthma treatment not managed effectively from 1st April until 29th April including insufficient handover, incomplete assessment, incomplete treatment plan, and medication, and minimal patient compliance.
• Death caused acute poorly controlled asthma contributed to by neglect whether due to provision or compliance.

HM Senior Coroner Mr Andre Rebello is to write a Regulation 28 Preventing Future Death Report on the issue of transfer of information.

Family of Ashley Gill 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.

A solicitor for 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.”

Deborah Coles, director said:

“This was an entirely preventable death. That a young man lost his life in these circumstances is shameful. This is the third inquest this month where the jury returned critical findings; Circumstances of this death again raises concerns about the quality of medical care afforded to the families.; Families, having lost their loved ones in prison need more than empty words that ‘lessons have been learnt.”

The family is represented by INQUEST Lawyers Group members Chris Topping, Leanne Dunne and Alice Stevens from Broudie Jackson Canter Solicitors and Counsel Ifeanyi Odogwu of Garden Court Chambers