Before HM Senior Coroner Mr Andre Rebello, Liverpool

Ashley suffered from chronic brittle asthma 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 2015. He was due to be released in just a few days. The jury at the inquest into his death concluded that his death was the result of neglect.

The inquest heard that healthcare staff at HMP Forest Bank, a privately operated prison, failed to transfer information relating to Ashley’s asthma and prescribed medication when he was transferred to HMP Liverpool on 1 April 2015.

In HMP Liverpool, where the healthcare services are run by Lancashire Care NHS Foundation Trust, Ashley did not receive a secondary health screening. He 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, and made a formal complaint which the prison failed to address. That Ashley did not receive his full medication was described by an asthma expert 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 found that neglect contributed to Ashley’s death.  Their findings included:

  • 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 1 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.”

Leanne Dunne, 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 of INQUEST said:

“This was an entirely preventable death. That a young man lost his life in these circumstances is shameful and raises concerns about the quality of medical care afforded to prisoners. This is the third prison inquest this month that has exposed systemic failings in the treatment and care of vulnerable prisoners. Bereaved families need more from the Prison Service than the 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."


Notes to editors:

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.