Interim Prisoner Ombudsman publishes report into the death of a prisoner

Published on April 17 2018

The interim Prisoner Ombudsman for Northern Ireland Brendan McGuigan has today published the findings of an investigation into the death of Mr David O’Driscoll.

Mr O’Driscoll died on the 12 August 2016 at Maghaberry Prison after he was found hanged in a cell in the prison’s committal house seven hours after arriving at the prison on the same day.

“From the outset I wish to extend my sincere sympathy to Mr O’Driscoll’s mother who has lost her son and his wider family for their sad loss,” said Mr Brendan McGuigan.

The investigation report found that a few hours before his death, Mr O’Driscoll’s mother had telephoned the prison to raise concerns about her son’s welfare after he had called her home from the committal house and threatened to kill himself.

After making enquiries, the Day Manager on duty at Maghaberry returned Mrs O’Driscoll’s telephone call and reassured her that her son was fine. Mr O’Driscoll died later that evening.

The investigation identified that no one had spoken directly to Mr O’Driscoll about the call he had made to his mother’s home, and the reassurance given to Mrs O’Driscoll was based on earlier interactions an officer on the committal landing had with him.

Speaking about the report Mr McGuigan said: “It is clear that some aspects of Mrs O’Driscoll’s telephone call could have been managed better and there was no evidence that a number of measures the Manager asked to be put in place were completed.

“The investigation identified an inadequate handover from NIPS day staff to night staff and poor record keeping, which regrettably is a recurrent finding in Prisoner Ombudsman death in custody investigations,”he said.

A clinical review conducted as part of the investigation raised potential concerns around the continuity of Mr O’Driscoll’s access to medication from his time in custody.

Following his arrival in prison, a committal nurse identified that Mr O’Driscoll required medication and made arrangements for this to be prescribed.

The prescription was dealt with by an out-of-hour’s GP service and two medications were prescribed, yet at the time of his death, Mr O’Driscoll’s medication had not been administered.

A separate clinical review of the resuscitation attempt however concluded that it was commenced promptly and carried out in as effective and efficient manner as possible when Mr O’Driscoll was found.

Commenting on the overall findings, the interim Prison Ombudsman said: “It is particularly distressing in this case that after being reassured by the prison about her son’s wellbeing, Mrs O’Driscoll was later told that he had died.

“This case highlights important lessons about how information provided from relatives of those in prison should be addressed.

“I wish to impress on prison staff the importance of staff handovers and record keeping which in this case, fell short of the standards required,” said Mr McGuigan.

The report makes 11 recommendations for improvement, the majority of which have been accepted by the Northern Ireland Prison Service (NIPS) and the South Eastern Health and Social Care Trust (SEHSCT).

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Notes to editors

1. The Prisoner Ombudsman’s Terms of Reference require the Office to investigate all deaths in prison custody. For further information see

2. The Ombudsman aims to provide the facts of the case and publish all material that is necessary to serve the public interest. This is balanced against legal obligations in respect of data protection and privacy for everyone concerned, and their views are therefore taken into account when publication is being considered. Mr O’Driscoll’s family indicated they are content for the full findings of this investigation to be published.

3. The previous Prisoner Ombudsman, Tom McGonigle, retired from post on 31 August 2017. His successor will be announced following the appointment of a Justice Minister. In the interim, Brendan McGuigan, Chief Inspector, Criminal Justice Inspection Northern Ireland, was asked by the Department of Justice to oversee the Office of the Prisoner Ombudsman until a successor to Mr McGonigle is appointed. It is in this capacity that Mr McGuigan published today’s report.

4. The following recommendations for improvement were made to the Northern Ireland Prison Service (NIPS) and the South Eastern Health and Social Care Trust (SEHSCT):


1. Record keeping - PECCS - The NIPS should ensure processes are in place to effectively record and communicate all relevant information about a prisoner’s welfare from PECCS to the receiving prison (Pages 13-14).

2. Reception procedures - Reception Officers should be reminded of the necessity of using all available, up to date information when assessing new committals; and of not relying on prisoners’ self-report or their prior knowledge of the prisoner (Pages 14-15).

3. Committal officer training - The NIPS should ensure that Reception and Committal staff are provided with training specific to their role (Page 18).

4. Performance Issues - The NIPS should address any performance issues that arise from this case (Page 20).

5. Staff handovers - The NIPS should remind staff that all relevant information relating to a prisoner’s welfare should be appropriately recorded in the relevant journals/reports; and that thorough verbal and written handovers must be conducted at the start/end of each shift (Pages 20-22).

6. Response to calls from concerned relatives - The NIPS should issue guidance for staff on how to respond to calls from concerned relatives (Page 22). This should include consideration of:

  • The prisoner’s custodial history and any recent/previous incidents of self-harm;
  • Listening to a recording of any call made by a prisoner where they have threatened to take their life;
  • Speaking directly to the prisoner;
  • Consulting with healthcare staff; and
  • Comprehensively documenting and sharing the actions taken by all staff involved to safeguard the prisoner.

7. Resuscitation - The prison governor should review the time taken for the ambulance to reach Bann House to determine if the process of an ambulance through the prison can be speeded up (Page 25).


8. First night assessment: The SEHSCT should review the information committal nurses should access as part of the first night in prison assessment (Page 16).

9. Resuscitation: The SEHSCT should ensure that adequate supplies of oxygen are available within each residential treatment room (Page 25).

10. Resuscitation: The SEHSCT should ensure that the nurses attending a resuscitation attempt record all events comprehensively (Pages 25-26).


11. Medication administration - The NIPS and SEHSCT should work collaboratively to ensure a system is in place to facilitate timely access to prisoners to administer medication (Page 27).