A Chinese man who died while being held in a Lanarkshire detention centre may have suffered two heart attacks in two weeks before he was found unresponsive in his bed.
Xi Biao Huang died at Dungavel Removal Centre in 2017 after frequently complaining about chest pains but never having seen a doctor during his time in detention.
A fatal accident inquiry found that the 54-year-old grandfather's death "might realistically" have been prevented if appropriate medical treatment was given.
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Several "systemic problems" at the centre were highlighted by Sheriff Dunipace that contributed to his death.
Staff recorded his language as Cantonese when in fact was a Taishanese speaker, with some understanding of Cantonese. It was also incorrectly recorded that Mr Huang spoke Mandarin.
In phone conversations with his family, Mr Huang would often state that he was "quite scared". He said he was suffering from neck pain, earache, and toothache and mentioned having seen a nurse, and going on occasions to a nurses’ room for medication.
He stated that whenever he did so there were no interpreters present and he couldn't communicate with them until he met his roommate who spoke Cantonese, and who interpreted for him when he received his medication.
He also mentioned that he had an appointment to see a doctor but that the doctor had not turned up.
The inquiry heard that Mr Huang had been born in China but had lived in Liverpool for about 15 years with his family when his immigration status was questioned after he lost his job in 2017.
He was detained at Dungavel on September 5 and died exactly two weeks later without ever seeing a doctor.
The day before his death, Mr Huang had spoken to nurses through a fellow Chinese detainee - who was not a Taishanese speaker. He was prescribed Peptac, a peppermint-flavoured remedy for indigestion.
It was concluded that he was probably experiencing a "cardiac event".
He was found unresponsive in bed by his roommate on the morning of September 19, 2017.
A port-mortem discovered "significant" heart disease and that Mr Huang had probably suffered a heart attack two weeks before his death and again two days before his death.
Dr Stephen Hearns, a consultant in emergency medicine, told the inquiry that had Mr Huang been taken to the hospital, the chances of him dying would have been "significantly reduced".
A number of recommendations were made by Sheriff Dunipace including that record-keeping be improved as well as access to GPs and translation services for detainees who are unable to speak English.
In his determination, he said: "Regrettably, there were a number of systemic problems inherent within the Dungavel establishment, which were exacerbated by individual clinical decisions which I have highlighted.
"I am also heartened to note that since the tragic death of Mr Huang that a number of changes have been introduced to deal with a number of these issues by Med Co.
"It is hoped that the recommendations will avoid other deaths in circumstances similar to those of Mr Huang
"I wish to convey my deepest condolences to the family and friends,some of whom attended the Inquiry with great dignity, of Mr Xi Biao Huang in relationto their loss."
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