An inquest into the death of a young inmate at a Rochester young offenders institute found he died of natural causes.

Daniel Adewole died in his cell at Cookham Wood YOI in July 2015, and the hearing heard earlier intervention may not have made a difference. The 16-year-old died as a result of sudden unexplained death in epilepsy.

He had been found unresponsive during a roll-call check at Cookham Wood Young Offenders Institution on the morning of July 4, 2015. The inquest into his death started at Archbishop’s Palace, in Maidstone, on Monday.

Daniel who had been in custody about a month and was due to celebrate his 17th birthday on July 11, was discovered shortly before 6am, but his cell door was not opened and an ambulance was not called until about 6.30am.

Yesterday, 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.”

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. The hearing 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 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: “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 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.

Two officers were then sent to the wing to open the cell which is when they discovered Daniel wet, under the bed clothes and unresponsive.

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 at about 6.50am.

It was 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.

During the inquest, when doctors were giving their expert opinion on what happened to Daniel, Dr Neil Soni told the hearing the young inmate was, on the balance of probability, most likely already dead when the cell door was opened.

Mr Adewole then asked the doctor: “Did the Prison Service kill my son rather than epilepsy?”

Mr Adewole had previously said his boy was given a death sentence because of neglect because his cell door had not been opened immediately.

Speaking at the time of Daniel’s death, 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.”

Mrs Harding concluded Daniel died of natural causes and although there was a delay opening his cell door, she said she was satisfied measures are now in place at the institution to prevent there being a delay in opening cell doors of unresponsive youngsters in the future.