An inquest into the death of a teenage boy who died after being found unresponsive in his cell at a young offenders institution (YOI) in Rochester, has heard earlier intervention may not have made a difference.
The hearing at Archbishops Palace in Maidstone into the death of Daniel Adewole, 16, heard he died as a result of sudden unexplained death in epilepsy.
Today, on the second day of the inquest, coroner Patricia Harding said: "Officers should have entered his cell sooner than they did, but it is not clear whether earlier intervention would have made a difference in this case."
Today the inquest looked into Daniel’s medical history and the medical care he received at Cookham Wood, as well as hearing a pathologist's report.
Yesterday, the inquest heard two operational support group (OSG) officers went out for a cigarette in between checking on him.
OSG Phil O'Neill said he had discovered the boy was not in his bed at Cookham Wood YOI when he did his early morning checks at roll-call time at about 5.53am.
He told the hearing he had looked through the peep hole of the cell on the second landing of Wing A, but had only seen bed sheets on the floor and could not see the young inmate.
He said: "I looked through the peep hole and there was no sign of the occupant. The duvet or bed covers were on the floor, I first thought it was an empty cell.
"I carried on checking and was one short when I counted the people. It didn't correspond with what should be on the landing."
After trying Daniel's door again on the way back along the wing and still not getting a response, OSG O'Neill went down to an office to speak to a colleague, OSG Sharon Bignall about the problem.
After telling his colleague the pair decided to go for a cigarette outside the wing, which took about 10 minutes, and then they returned to rouse Daniel at about 6.14am.
Daniel, who suffered from epilepsy, still did not respond however, and the pair, despite having a key in a sealed pouch to open any cell in an emergency, decided to go back down to the ground floor office to call the custody manager, Michael Lamb, for assistance.
Custody manager Lamb, then requested for two prison officers to be sent to the wing to open the cell which is when they discovered him wet, under the bed clothes and unresponsive.
Daniel's dad, David Adewole
The officers, Paul Calvert and Alison Stevenson tried CPR on Daniel, but he was later pronounced dead by paramedics who were called to the prison in Sir Evelyn Road at about 6.50am.
Evidence from prison officers was heard on the first day of the hearing which is expected to go on for three days.
It was also disclosed during the hearing the OSGs were not aware Daniel suffered from epilepsy and had not been told about his condition during their handover from day staff.
At a pre-inquest review, held last year, his dad, David, said Daniel had moved in with his mother in Tilbury, Essex, before he was arrested for assault and taken to the young offenders' institution.
He added: “My boy was given a death sentence because of neglect. They left him alone for 45 minutes.”
Senior coroner Patricia Harding said adjourned the hearing at about 2.15pm today and more evidence from other prison staff will be heard tomorrow.
Speaking at the time, a prison spokesman said: “Staff attempted resuscitation and paramedics attended but he was pronounced dead at approximately 8am.
“Every death in custody is a tragedy and we will always seek to improve our procedures for caring for prisoners, including young offenders, where possible."