Investigation Report into Death In Custody of John Deery

Published on December 08 2010

The Prisoner Ombudsman, Pauline McCabe, today made a total of 12 recommendations following her investigation into the death of Mr John Deery, 50, who died by suicide whilst in the custody of Maghaberry Prison on Friday 28th August 2009.

The investigation into the circumstances of Mr Deery’s death found a number of concerns in connection with his care, some of which were identified in previous Death in Custody investigations, including that of Mr Colin Bell, and where recommendations were made and accepted.

The Prisoner Ombudsman reported on the death in custody of Mr Colin Bell in January 2009.

Releasing her Investigation Report, Mrs McCabe said: “During the course of the investigation into the death of Mr Deery, I came across areas of concern that were previously identified and where the recommendations I made were accepted. I feel that it is very regrettable that these important issues are emerging again.”

Areas and arrangements of concern which were raised previously and found again during the investigation included the carrying out and recording of observational checks by staff; the carrying out of conversational checks; the arrangements for handovers between shifts; and the culture of care in respect of vulnerable prisoners.

The investigation also found that Mr Deery had spent only 11 minutes or less out of his cell during the four days before his death and that he did not, as required by Prison Service policy, have a meaningful care plan or an assigned care coordinator. It also found that while most of the medicines Mr Deery was taking before entering prison were prescribed in his first two days of entering, two medicines, including an anti-depressant, were not prescribed until the day he died.

Pauline McCabe said:

“There was evidence that some staff some of the time really did their best for Mr Deery. There is also no doubt that efforts have been made since the death of Colin Bell to improve policy and practice in the care of vulnerable prisoners.”

“It was however very evident that those efforts have not been effective in delivering real change on the ground. Many of the problems I have identified appear to stem from wider issues related to leadership, management and prison culture.”

“Our entire prison system, which accounts for massive annual public investment, is desperately in need of a coherent strategy that addresses these overall issues.”

“I look forward to reading the findings and recommendations of the review team chaired by Dame Anne Owers in the hope that their deliberations will provide the way forward.”

Further inquiries should be directed to David Cullen at ASG on 028 90 80 2000, mobile on 07919 598 710, or by email at

Notes to editors:

The Prisoner Ombudsman terms of reference (found at require her to investigate all deaths in prison custody since September 2005.
When the office was given this role no additional resources were provided.
Copies of all death in custody investigation reports published to date can be found at
It will be normal practice for copies of Death in Custody investigation reports to be placed on the website with notification to the press through a press release.
Investigations are ongoing into 4 deaths in prison custody