The family of a man who died in Wandsworth jail while on remand for stealing a gingerbread man in the Crodyon riots have said lessons must be learned to ensure no more lives are lost.
James Best, 37, was being held on remand at HMP Wandsworth when he collapsed and died of a heart attack after a gym session on September 8, 2011.
At an inquest into his death which concluded on Friday, the coroner recorded a narrative verdict saying that "opportunities to save his life were not maximised".
James had a history of psychiatric and medical problems including Crohn's disease and asthma. In accordance with prison service policy he should not have been allowed to use the gym without the approval of healthcare staff.
The inquest heard evidence that the gym assessment policy had broken down, with assessment forms being signed by prisoners rather than officers and no referrals being made to healthcare.
Nancy Collins, a specialist lawyer at Irwin Mitchell representing James' family, said: "The circumstances of James' tragic death are symptomatic of a prison service in crisis. The evidence heard at the inquest shows that James was failed by the prison staff, the prison healthcare staff and the London Ambulance Service.
"Unless urgent measures are implemented to address those failures there is a very real risk that there will be other avoidable deaths in prison custody.
"James' foster family seek to ensure that lessons are learnt from James' death. So that other prisoners' lives are protected."
The inquest heard conflicting evidence about the efficiency of the response of healthcare staff to James' needs following the heart attack. In addition there were lengthy delays with the dispatch of an emergency ambulance.
The call from the prison to the London Ambulance Service lasted 13 minutes despite an officer telling the London Ambulance Service that James was having difficulty breathing and that the nurse attending to James was screaming for an ambulance. James was declared dead as the paramedics arrived. The delay in their arrival deprived James of the opportunity of their expert assistance.
James' foster mother Dolly Daniel who looked after him from the age of 15, said: "he was such a loving person and our other children looked up to him as a hero. He was always looking out for friends and we just can't believe he has gone.
"To find out that his death may have been avoided if there were proper checks on his health is so hard to take in.
He was let down by the justice system and they basically ignored his health issues. I just hope that the procedures can be improved so that no one else has to suffer as we have."
In 2011 inspectors at HMP Wandsworth reported that the prison, which holds over 1,500 prisoners, was branded the most "unsafe" in the country for inmates. There were 11 deaths at the jail between January 2010 and June 2011, and this week's inquest was the third this year into the death of a prisoner there.
James had been convicted for stealing from a looted bakery. He was remanded in custody awaiting sentence. This was his first time in prison. At the time, magistrates were issued with advice from the courts and tribunals service to disregard normal sentencing guidelines for offences committed as part of the 2011 riots. Consequently there was a surge in the prison population, putting increased pressure on already crowded prisons.
