Acting Director of Public Prosecutions Kulandra Ratneser?s decision not to press charges in connection with the death of Steven (Pepe) Dill will not have come easily.

No one, in this day and age, should die of complications arising from asthma as Mr. Dill did.

Clearly, communications both between the responsible officers and with the duty nurse were dreadful. Nonetheless, based on the evidence presented at the inquest into Mr. Dill?s death, it would have been difficult to pinpoint one action or one person who was directly responsible for the Prison Farm inmate?s passing.

Instead, it would appear that Mr. Dill?s death was a result of a breakdown in the prison system itself, and the system would end up on trial in the event of a prosecution.

That is still possible. Mr. Dill?s family are likely to sue the Government and the Prisons Service over his death, and rightly so. The Government would be wise to offer a generous settlement rather than have the horrendous shortcomings of the service exposed in public once again.

Perhaps the most disturbing facet of all of this is that there has been no public statement from either the Prisons Service (or the Department of Corrections as it is now called) itself or from the Ministry of Home Affairs with regard to what steps have been put in place to avoid a repeat of this fiasco.

Nor does there seem to have been any action taken against the officers involved. While there may not sufficient evidence to begin a prosecution, even the blind can see that the officers concerned were remarkable negligent.

To be sure, the prisons have plenty of problems, with a Commissioner who has had his authority overthrown, continued problems with drugs, continued complaints about the lack of rehabilitation and systemic overcrowding.

Simply deciding where to start is a massive and forbidding task.

But none of that excuses the failure to put procedures in place to ensure that prisoners will not die unnecessarily, if in fact that has not happened.

The public needs to be reassured on this question, so that at least some good will come out of this episode which has brought the Prisons Service to an even lower ebb than most people thought possible.