James Best’s death in prison, where he was being held for stealing a gingerbread man during the August 2011 riots, was one of the most tragic episodes of the disturbances which shook England that summer.

Mr Best, who took the gingerbread man from a looted bakery in Croydon, had at that time only come back to the UK after a period spent living and working in Portugal, and a month before the riots he was sectioned under the Mental Health Act after self-harming in public.

But what makes his death and the events surrounding it worse is that he should never have even been imprisoned in the first place, Mr Best’s brother has said.

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Owen Daniel told The Independent that his 37-year-old brother, whose death from a heart attack a jury found to have been preventable, should have been placed in care due to his mental health issues, rather than in a cell in one of Britain’s most dangerous prisons. And Mr Daniel warned that – without real change – his brother’s death will not be the last preventable tragedy at HMP Wandsworth.

At his inquest, Westminster Coroner’s Court heard from prison staff that Mr Best was “failed by the system”. Although the court found that he died of natural causes, the assessment of the performance of the prison staff and ambulance service was scathing.

“Without a doubt there is a risk that this could happen again. Everyone in court said they are making the changes. They are saying that the system that should have been in place then is in place now. But that doesn’t give us much confidence,” said Mr Daniel, from Hastings.

James Best was on remand awaiting sentencing when he died; his case was one of the many processed speedily by the courts in the immediate aftermath of the riots. And his brother said he believed that the pressure placed on the prison system by the influx of prisoners immediately after the riots, coupled with institutional failings, were behind his Mr Best’s death.

In their verdict, the inquest jury stated: “The initial prison officer response did not recognise the urgency of James Best’s needs and the appropriate level of medical support required.” And the jury heard that there were delays in getting the paramedics to Mr Best’s side.

Mr Daniel said that his brother complained of not getting the care he needed in a letter sent shortly before his death. He said: “James wrote to me before he passed away and he described not being able to get hold of medicines he thought he should have been able to get hold of and called the medical system a disgrace. He had not seen anyone from the mental health team, despite asking to. He mentioned to me in the same letter that he was considering self-harming, which would not have been him saying ‘I need attention’. For him, that would be serious; he had a history of it.

“I can’t imagine he would only have said it to me in the letter, he would have said it to someone in the mental health team if he had been given an appointment. We heard in the inquest that they didn’t believe he was a suicide or self-harm risk. I beg to differ; those were things that would have been picked up, had they looked for them.”

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Mr Best went to live with a foster family as a teenager and had shown promise as a cricketer. By the time he went to prison, he was overweight and had health problems which should have excluded him from using the prison’s gym. But, after a heavy training session, he suffered a heart attack.

HMP Wandsworth has been at the centre of controversy due to the number of deaths that have occurred there. Inspectors called it “unsafe” in 2011 after they found 11 deaths between January 2010 and March 2011. And the campaign group Inquest said that Mr Best’s inquest was the third this year into a death in custody there.

“They just don’t care because they are just managing numbers, like you would with sheep on a farm,” said Mr Daniel. “They are not particularly concerned about individuals with those complacent attitudes, it is difficult to see how things will change, unless they legislate.

“We need to see quicker, more accurate assessment of mental health issues and to get people the attention they need. James should never have been in a prison, he should have been in a hospital. Maybe the mental health team could have seen that.”

A Prison Service spokesman said: “We will consider the inquest findings to see what lessons can be learned in addition to those already learned as a result of the investigation conducted by the Prisons and Probation Ombudsman.”

The verdict on Wandsworth: 'Unsafe, demeaning and abusive'

Inspectors visiting Wandsworth prison in 2011 were scathing about its safety record. There were 11 deaths in custody between January 2010 and March 2011 and “typically, there were about 32 incidents of self-harm each month”.

They also saw “frequently indifferent and sometimes abusive staff interactions with prisoners”. They admonished management at Wandsworth and Pentonville for colluding during inspections to move difficult prisoners, hiding them in the system.

The inspectors wrote: “The treatment and conditions of too many prisoners at Wandsworth was demeaning, unsafe and fell below what could be classed as decent.”