THE surge in the prison population after the 2011 riots did not contribute to a Croydon man's death, an official report has concluded.
The Prisons and Probation Ombudsman found "failings" around the care of James Best at Wandsworth prison, but said overcrowding was not behind these failings.
In the report, published last week, the ombudsman added that the death of the 37-year-old, who was awaiting sentencing for stealing a gingerbread man from a looted London Road bakery, was "unpredictable" and not preventable.
Mr Best died from a heart attack on September 8, 2011, after exercising vigorously on the rowing machine at the prison's gym.
The 1,665-capacity prison housed 1,680 prisoners around the time, compared to 1,599 in June that year and 1,625 in September the year before, according to the report.
But the ombudsman wrote: "Whilst some failings were identified in the investigation, there is no evidence to indicate that population pressures or a large number of new arrivals at the prison were a significant contributing factor to these.
"Indeed, the clinical reviewer comments that his immediate physical health needs were identified and managed appropriately on his arrival."
Failings after that, however, including over the gym induction process, scarce emergency medical equipment, and Mr Best's poor mental health care, sparking a raft of recommendations in the report.
Mr Best had tried to kill himself three weeks before entering prison for the first time, and was taking anti-depressants.
The prison doctor who saw him a day after he arrived made an "urgent" referral to the mental health team, but no consultation was arranged.
Gym induction procedures have been tightened since the death of Mr Best, who visited the gym with his cellmate after they each smoked a cigar given to them by a prison workman, the report says.
He was allowed to use the gym unsupervised despite suffering from asthma, Chrons disease, and recording high blood pressure when he arrived.
The report also recommends better placing of emergency equipment, such as defibrillators, around the prison.
The on-call nurse had to collect an emergency bag from a separate wing and arrived at Mr Best's cell "a number of minutes" after an emergency call was made to say he had collapsed.
However, the ombudsman dismissed concerns raised by Mr Best's foster brother, Owen Daniel, that he might have been better placed in somewhere with more support for mental health patients.
The report concludes: "I do not think his death was preventable.
"He had a sudden, unpredictable heart attack, in the absence of a prior history of heart disease, and died of a cardiac arrest."
At his inquest last month, Westminster coroner Dr Fiona Wilcox recorded a narrative verdict saying that "opportunities to save his life were not maximised".
Mr Daniel has previously paid tribute to his foster brother, telling the Advertiser: "I would never have become half the man I am today without his influence; he was a true inspiration to our family."