The family of a teenager who died following a brain haemorrhage at HMP Cookham Wood have slammed failings in communication and observation at the young offender's institution near Rochester.

After a seven-day inquest, which concluded at the Shepway Centre in Maidstone yesterday, a jury found that 16-year-old Caden Stewart died of natural causes and that there had been “inadequate reporting" and "insufficient communication" between prison officers and healthcare staff prior to his death.

While the jury could not conclude these factors contributed to Caden’s death, they did record that communication issues had led to healthcare officials failing to attend Caden when he complained of a headache and chest pains.

The inquest, held before Patricia Harding, senior coroner for Mid Kent & Medway, heard that Caden had reported the symptoms and appeared to be in discomfort after playing football and attending the gym on June 26, 2019, but that gym staff failed to pass on the information to healthcare officials and other officers.

One of the physical instructors was even said to have been reading a magazine and not attending to Caden, despite the teenager being clearly in the line of sight and in pain.

He was then taken back to his cell where he later rang his emergency bell and asked for medical help, and while the prison officer who attended Caden stated that he passed this message on, nurses based at the site deny receiving it and did not attend.

The teenager was found unresponsive in his cell more than four hours after asking for medical help, and was taken to Medway Hospital where he received a CT scan which showed he had suffered a brain haemorrhage.

He was transferred to Kings College Hospital and taken for urgent surgery, but was formally pronounced dead the following day.

A post-mortem examination revealed the immediate cause of death was a haemorrhage caused by an arteriovenous malformation (AVM).

The inquest also heard evidence from a consultant doctor who was of the view that, had Caden received the appropriate treatment at Kings College Hospital more quickly, it was more likely than not he would have survived.

A much-loved son, brother and friend, Caden was also described at the inquest as an outgoing and vivacious person with a great sense of humour, and had no previous medical concerns.

A statement from his family issued after the hearing said: "We sincerely believe that if Caden had received treatment earlier, he would still be with us.

"These children are in the care of HMP/YOI Cookham Wood and their communication and observation skills are severely lacking. Caden was asking for help from the people who were meant to be looking after him.

"It breaks our hearts that we were not there to help him that day, and that the people who were trusted to look after him failed him and failed us.

"Although we are grateful for this inquest process, having to re-live Caden's death has been extremely hard. Caden’s death has been very hard on us, the family, and his friends.

"We are pleased with the outcome of the inquest. We hope that lessons are actually learned this time around, as it is obvious from previous inquests that not much had changed and not much had been learned. We hope that no other family have to go through the same thing."

Lois Clifton, of Simpson Millar solicitors, who represented the family, said: “It has been a long journey for Caden’s family to get to this result and ensure that the tragic circumstances which led to Caden’s death were properly investigated.

"Caden was a child. Staff should have properly communicated to ensure that Caden was monitored and assisted when he had asked for help. To hear from a clinician that there was a chance Caden would have survived had he received appropriate treatment confirms the family’s concerns that there were missed opportunities in the hours leading to his death which could possibly have saved him.

"HMYOI Cookham Wood has a responsibility to the children detained there, and the family hope that lessons will be learnt to ensure this does not happen again. Deaths of children whilst in the care of the state show, time and again, that YOIs are ill-equipped to protect detained children".

Deborah Coles, director of the charity INQUEST, which provides expertise on inquests concerning state-related deaths, said: “Caden’s obvious distress and calls for help were ignored by staff and as a result a potentially preventable death might have been avoided. Yet again the health and welfare of children in the care of the state has been found wanting. This reinforces our concerns about the inherent risks of prisons for children”.

A Prison Service spokesperson said: “Our condolences remain with the family and friends of Caden Stewart.

“We will consider the findings of the Coroner’s report once received and implement recommendations accordingly.”

Read more: all the latest news from Medway.