A convicted child rapist was left to die in the medical wing of an English prison after he vomited blood in the prison dining hall.
Peter Gibson, 68, was two years into a 13-year sentence when he died, the Mirror reports. He had been convicted of 15 sexual offenses, including four counts of rape against two young girls.
Gibson was reportedly left alone in the medical wing, where he waited for an ambulance. He was there for several hours and did not receive any treatment.
"It struck me as being almost unbelievable that what happened in this case happened," coroner Andrew Tweddle said, according to the Mirror. "That Mr. Gibson was left unsupervised for quite a long period of time when there was clearly a medical concern from a nurse and a doctor."
Tweddle also criticized the prison staff for using the wrong codes to communicate Gibson's condition over their radios.
"It is time, in fact it is long past time, that the code systems are properly understood and followed," he said. "Prison staff may panic when they find a body or someone dying, but they should use the codes."
There was reportedly confusion among the medical staff because two ambulances were called in a short period of time -- one for Gibson and another for another inmate who had cut open an artery.
Tweddle's autopsy concluded that Gibson died of organ failure.
As a result of the incident, G4S, the company that runs the health care system for a number of prisons in England, has updated its protocol to ensure patients receive proper care in the medical wing.
Pedophiles have a notoriously rough time in prison, where they are viewed with contempt by fellow inmates. This is because many prisoners have children, and also that many were molested as children, according to ABC News.
"[Pedophiles] are at risk of being murdered, having their food taken, having their cells defecated and urinated in," prisoner's rights activist Leslie Walker told ABC News. "Their life is truly a living hell."