25th March 2013

A jury has severely criticised HMP Wandsworth and the London Ambulance Service (LAS) for ‘failures within the systems and the consequent delays’ which meant not enough was done to attempt to save the life of a man detained during the 2011 Croydon riots for stealing from a bakery.

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 8 September 2011. At the conclusion of an inquest into his death on Friday 22 March, the coronerrecorded a narrative verdict describing the shambolic response once James became ill. The jury described the timing of the call to the LAS, and the lack of priority given to the call by the LAS, as both ‘potentially contributing to’ James Best’s death.

James had a history of mental ill health 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.

Evidence at the inquest raised serious concerns over the efficacy of the response of healthcare staff to James Best’s 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 LAS that James was having difficulty breathing and repeated requests for an ambulance by the nurse attending to James. James was declared dead as the paramedics arrived.

This was James Best’s first time in prison. At the time, magistrates had been 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.

James Best’s 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 – he should never have been in prison in the first place – 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.”

Deborah Coles, co-director of INQUEST said:

“Not only should James never have been imprisoned in the first place but there remain serious questions about why a prison like Wandsworth that has seen a disturbing number of deaths is still failing to implement basic policies and procedures designed to protect the health and safety of its detainees.

“The Prison Service needs to urgently review and act on the serious systemic failings exposed by this inquest. Whilst sentencing policy remains outside the scope of the inquest serious questions must be asked of Government as to the decision to imprison a vulnerable man for such a trivial offence. ”

Nancy Collins, representing James Best’s 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.”


Notes to editors:

  1. 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 prisoners. There were 11 deaths at the jail between January 2010 and June 2011, and last week’s inquest was the third this year.