On Friday, a Coroner's jury returned virtually the only verdict it could have in the death of prison inmate Stephen Mansfield (Pepe) Dill.

It ruled that he died almost two years ago as a result of "the absence of timely medical intervention from the complication of bronchial asthma, which was possibly exacerbated by poly-drug abuse."

Due to changes in the way that inquests are now conducted, the jury could not say who was responsible for this "absence" of care. But it is still quite possible that criminal proceedings can be brought.

That will be a decision for the Director of Public Prosecutions, who will weigh the case quite carefully in determining whether there was sufficient evidence of negligence on the parts of one or more of the prison officers to lead to a conviction.

In the meantime, it is astonishing that there does not appear to have been any form of inquiry by the Prisons - now the Department of Corrections - into the events leading to Mr. Dill's death nor has there been any public announcement that steps have been put in place to avoid a repeat of this terrible tragedy.

It would not be responsible at this point to say that there was any one person or persons whose actions were directly responsible for Mr. Dill's death. But it is fair to say that a whole series of decisions - or a lack of decisions in some instances - created a chain of events that led inexorably from a relatively minor and easily treated medical problem to one person's death.

Had events taken a different turn at any single moment on the night that Mr. Dill died, then he probably would have lived. And it is just as likely that the public would never have known a thing about it. But they never did. And now Mr. Dill is dead, the victim not so much of asthma, or even heroin, but of a sheer failure on the part of the officers responsible for his care to act.

However, this was not simply a matter of officers failing to fulfil their duties. In this case the prison system failed and the Prison Service failed. It failed to adequately train its officers to recognise a growing medical emergency.

It failed to ensure that there were adequate communications systems in place to make sure that when a nurse took three hours or more to respond to a call that there was a back-up system in place.

It failed to prevent inmates from using drugs that made Mr. Dill's condition worse.

Ultimately the Prison Service failed Mr. Dill.

Nothing can be done now to bring him back. But it is not too late for the proper steps to be taken to prevent a repeat of this tragedy and to ensure that those who are put in the care of the prisons get the care they need.

That's the least Government and the Prisons Service owes the family of Mr. Dill.