Investigation report into the death in custody of David Brown

Published on August 05 2014

The Prisoner Ombudsman for Northern Ireland today published an investigation report into the death of a prisoner, David Brown. Mr Brown died from a brain haemorrhage at outside hospital on 15th December 2012, while in the custody of Maghaberry Prison.

Toxicology tests revealed painkilling drugs in his system. These had been prescribed to him, and were at concentrations that lay within their respective therapeutic ranges. No other common drugs were detected in his system. This is important as there was speculation about a white powdery substance that was found around Mr Brown’s nose at the time of his death. 

When Mr Brown was discovered in an unresponsive state in his cell, the NIPS response was inadequate: he was left unattended for five minutes; the alarm was not immediately raised; other prisoners were not locked; and the nurse was not made aware that it was an emergency situation.

However our clinical reviewer was not critical of his medical management in prison, and did not feel that an opportunity to achieve an earlier diagnosis existed, or that there would have been a possibility to achieve an alternative outcome for Mr Brown. 

This investigation has identified four matters requiring improvement, two of which (post-incident support for staff, and record-keeping) were previously made, and accepted by the Prison Service and the South-Eastern Health and Social Care Trust. 

The NIPS have accepted the recommendations of this report, and said they have already been implemented. The SEHSCT also accepted their recommendation, and advise that it has been reiterated to their staff, and will also be considered at a Lessons Learned forum. 

Prisoner Ombudsman Tom McGonigle, in expressing sympathy to the next of kin, said “While some things could have been done better, a key finding of this independent investigation is that there was no possibility to achieve an alternative outcome for Mr Brown.” 

Media contact:
McCann Public Relations, Telephone: 02890 666322
Maria McCann: 07802934246 or Natalie Mackin: 07974935855

Notes to editors:

1. The Prisoner Ombudsman’s Terms of Reference require the Office to investigate all deaths in prison custody since September 2005. Please see  for further information.

2.  In line with the Prisoner Ombudsman’s Terms of Reference a copy of this report has also been sent to the Coroners Service for Northern Ireland.

3. Publication of Reports
The Prisoner Ombudsman strives to ensure that readers can establish the facts of the case, and that all necessary information is shared in the public interest.  This is balanced against legal obligations in respect of data protection and privacy, and we therefore take careful account of next of kin views when considering publication.  In this case Mr Brown’s next of kin were content that all the investigation details should be made public. They are represented by Harte Coyle Collins Solicitors, to whom any enquiries should be addressed.