A jury has called on Westgate prison to ramp up drug interdiction, train prison officers in medical procedure, and communicate better with families of inmates in the wake of medical emergencies.These recommendations came at the conclusion of an inquest into the October 2009 death by heroin overdose of 37-year-old inmate Kino Outerbridge.During its three-week enquiry into the cause of his death, the jury has heard of widespread drug abuse within the prison walls, and home-brewing of makeshift liquor.But the court was unable to learn how the heroin that killed Mr Outerbridge, a former addict, was brought into Westgate — with one witness telling the jury: “I can’t let those tricks get out.”It took a few hours for the eight-man jury to reach a unanimous conclusion that Mr Outerbridge died of an overdose between 8am and 8.30am on October 6, 2009.After hearing of the struggle by officers and inmates to revive the unresponsive man, the jury appended a rider to the verdict, in which they advised for all prison officers to get trained in CPR, as well defibrillator use.Defibrillators should be supplied to all prison units, and training in emergency procedure be included in officer training, and mandatory annual refresher courses.The jury further recommended better interdiction to “reduce or eradicate” smuggling — and that Westgate improve its communications with inmates’ family members.It follows a complaint by Mr Outerbridge’s mother, Shyrl Outerbridge, that her persistent difficulties in learning exactly how her son met his death had caused her to suspect a cover-up in the Island’s jail.In his morning summary of the proceedings, Coroner’s officer Sergeant Lyndon Raynor told the jury there was no dispute as to the cause of Mr Outerbridge’s death — or that drug use by prison inmates is “rampant”.“Whatever you had on the outside would be available on the inside,” he said.As for Mr Outerbridge, he said: “The evidence is that it was a drug overdose. What may be some area of concern is what actions took place by prison officers once he collapsed.”The inmate “died of a heroin overdose in a facility where he was not supposed to have access to such drugs”.Sgt Raynor continued: “There’s a problem within the prison system and hopefully this inquest will go some way in addressing the deficits that have been highlighted.”Crown counsel Martin Johnson reminded the jury that Mr Outerbridge had been jailed on August 17, 2009 and was placed in cell 40. On the morning of his death, the victim had gone next door to his friend in cell 38, where he collapsed at 8.12am. The court has heard that Mr Outerbridge died seven to 20 minutes after ingesting the drug.At 8.20am, officers called 911; at 8.38am, EMTs from the Fire Service arrived. At 8.45am, an ambulance arrived for King Edward VII Memorial, where Mr Outerbridge arrived at 9.29am. He was declared dead at 9.40am.In her summation, lawyer for Mr Outerbridge’s family Victoria Pearman said she hoped recommendations would come out of the inquest so that, “in the words of Mrs Outerbridge, her son didn’t die in vain”.“She told us she is a believer in omens,” added Ms Pearman, “and that her son Kino Outerbridge had a cousin, Pepe Dill, who was born on the same day as him, and who also died in prison.”Steven Mansfield (Pepe) Dill died on the Prison Farm in 2001; an inquest into his death by asthma uncovered evidence of extensive drug use on the inside.Following her son’s death, Mrs Outerbridge’s concern had been that “nobody told her anything”, Ms Pearman told the court.“She could not get documents or recordings, and when she had a conversation with Commissioner Eddie Lamb, you heard her say that she hoped it was not a cover-up,” Ms Pearman told the jury.The lawyer expressed frustration that the CCTV footage provided to the inquest didn’t include the victim’s collapse or the circumstances leading up to it.“It’s very, very difficult indeed, on behalf of my client and her family, when what we refer to in the law as the best evidence rule would have been the footage of those cameras,” she told the jury. “But for some inexplicable reason, the cameras’ footage that was surrendered to these proceedings starts at 8.20am, according to the date on it. It doesn’t seem to make a lot of sense, when you have 24-coverage.”The inquest was provided with footage from two cameras from the E1 unit. According to Magistrate Juan Wolffe, the jury was provided only with “recordings specific to the incident, not prior” — and the earlier footage was unavailable because it gets recorded over every three months.Mrs Outerbridge has expressed concern that inmates were allowed to attended to her son following his collapse.“It’s difficult to be upset because it certainly does appear that they jumped in to try and come to the assistance of Kino Outerbridge,” Ms Pearman continued. “They appear to have had an urgency one might have hoped to have had from others.”Instead, she said, prison footage shows an officer downstairs “just sitting there like he’s watching a TV show”, and other white-shirted officers speaking in a huddle but not rushing to the fallen man’s aid.As for smuggling of contraband, Ms Pearman said, the jury heard from prison officer Craig Clarke that “no prisoner in the world has a sterile environment”.“I think that’s his way of reminding us that no matter how hard you try, things get in. That may be so. But that can never be an excuse for not trying very hard to stop it. It would be most unfortunate to say that drugs are going to get into prison, so what can you do.”She recalled a former client who entered the then Casemates prison a cannabis user, but emerged addicted to heroin.The lawyer also questioned why “there did not appear to be the examination that you might have expected” in the aftermath of Mr Outerbridge’s death, which happened scant minutes after another officer saw him on the lower level in normal condition.Rolling papers and tobacco from his cell floor appeared not to have been tested. Nor was a length of torn cloth weighted with soap and attached to cell 38’s window bars.Continued Ms Pearman: “We didn’t hear anything about searches being done that day.”And the “elephant in the room”, she said, was a meeting held by prison officers in the hours following Mr Outerbridge’s death — the details of which none of the witnesses seemed to recall.“Why do we have statements from high-ranking officers referring to a debriefing, and have tacit acknowledgment from two basic officers that there was some kind of meeting, but no one remembers what that meeting was about?”She reminded the jury that the inquest heard earlier from principal officer Gerald Bean that the meeting was “not really a debriefing”, but that the two officers in charge of E1 that morning “had their information correct”.It took about three hours for the jury to reach its conclusions yesterday, which Mr Wolffe hailed as “eminent sense”.“It’s certainly in line with what I was thinking,” the magistrate told them, adding that he would use it in his own recommendation to prison authorities — “in the hope that they can take further action to ensure that no other inmate will meet the same fatality as Mr Outerbridge”.Accepting the verdict on behalf of the victim’s family, Ms Pearman added: “I hope it won’t fall the way of policies and sit in a binder somewhere.”