Investigation Report into the Death in Custody of Aaron Wayne Hogg

Published on June 27 2012

The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today published her report into the death of 21-year-old Aaron Wayne Hogg, who died by suicide while in the custody of Maghaberry Prison on Sunday 22 May 2011.

Mr Hogg had a number of background risk factors that indicated an increased risk of
suicide in custody. The investigation found clear evidence that, during his time in
custody, Aaron experienced sleeping difficulties; was abusing prescribed medication
and illegal drugs; continued to be concerned about things that had happened to him
in the past; and in his last days, was very troubled by hallucinations.

The investigation found that there were many respects in which Aaron did not act in
his own best interest. It was noted, in particular, that Aaron did not tell staff about the
deterioration in his mental health; did not take his medication as prescribed; asked
visitors to source illegal substances for him; and took non-prescribed medication and
illegal substances.

The investigation also, however, identified significant issues of concern in connection
with Aaron’s care in prison. At the time of his death, Aaron was receiving a monthly
supply of his prescribed antipsychotic medication without risk assessments being
completed and it was clearly the case that he was able to trade his prescription
medication and obtain a range of illicit substances in prison. The investigation found
that at the time of Aaron’s death, he should have been in possession of 113 tablets of
his prescribed medication, however just one tablet was found in his cell. Aaron’s
autopsy also revealed the presence of at least six non-prescribed medications and
cannabis within his blood and urine.

The investigation found that Aaron’s speech was slurred on several consecutive days
prior to his death; however there was no evidence that prison staff considered any
action in response, such as a referral to prison healthcare, carrying out a cell search
for drugs or monitoring Aaron’s phone calls. During his five months in Maghaberry,
Aaron was drugs tested just once and no consideration was given by staff to the
need for any mental health and/or psychiatric input for him, or to referring him to
addiction support services.

The report points to twenty four matters of concern requiring action by the Northern
Ireland Prison Service and South Eastern Health and Social Care Trust.

Releasing the report, Mrs McCabe said:
“This investigation has highlighted, yet again, the importance of effectively
addressing the misuse of drugs within Northern Ireland prisons. Regrettably, there
appears to be an acceptance that a level of illicit substances, drugs trading and an
associated culture of bullying are inevitable in prison. Furthermore, it has come to
my attention a number of times recently that the Prison Service does not properly
implement its own bullying policy and, in particular, does not adequately investigate
bullying incidents and take appropriate action. A more robust and consistent
approach to tackling the supply of illicit substances and associated bullying is
needed. It is also essential that appropriate action is taken when prisoners are very
clearly abusing prescription or non-prescription medication is needed.
The South Eastern Health and Social Care Trust’s role in managing the
administration of prescription medication and delivering therapeutic interventions to
address demand must be fully integrated with a simultaneous effort by the Northern
Ireland Prison Service to curtail the supply of drugs within prison and prioritise the
delivery of purposeful regimes. This must be addressed vigorously and
comprehensively if the significant efforts now being made to rehabilitate offenders
are to deliver the required results.

While it has been suggested that all prisoners should be administered with only one
dose of medication at a time, it is my view that the cost and staff required to support
this arrangement would only serve to inappropriately redirect resources needed
elsewhere within the delivery of prison healthcare. In this context, it is to note that
prisoners who want to try and address their addiction problems are currently waiting
six months for a first appointment with ADEPT (Alcohol and Drug Educational
Programme and Training) services. The circumstances surrounding Aaron’s death
do however emphasise the need for supervised administration where a prisoner has
a history of abusing medication or is deemed to be at risk of self harm.”
Mrs McCabe added: “The need for a fully joined up approach between the Northern
Ireland Prison Service and the South Eastern Health and Social Care Trust as part of
their programmes for change is critical.”