Investigation report into the death in custody of Frances Mc Keown

Published on November 28 2012

The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today published her report into the death of 23-year-old Frances McKeown, who died by suicide while in the custody of Hydebank Wood Women’s Prison on Wednesday 4 May 2011.

Frances was a vulnerable inmate with an extensive history of self-harming and psychiatric hospitalisation prior to her committal on remand in September 2010. The investigation found clear evidence that, during her time in custody, Frances made her intention to die known to prison and healthcare staff, as well as other prisoners.

The investigation acknowledges the efforts made by staff to help and support Frances. It was noted, in particular, that SPAR (Supporting Prisoners at Risk) booklets were opened on five occasions when Frances was considered to be vulnerable and at risk; that she engaged in a number of therapeutic interventions, including counselling services; and she attended and enjoyed various purposeful activities during her time in custody.

The investigation also, however, identified serious shortfalls in connection with Frances’ healthcare in prison. Although it was known that Frances had a complex medical history and threatened suicide whilst in prison, her medical notes were not requested and she did not see a psychiatrist until more than six months after her committal. Issues were also identified in connection with the arrangements for prescribing and supervising Frances’ medication.

The report points to eighteen 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: “Frances was a troubled girl and her mental health issues were extremely challenging, but she responded well to therapeutic interventions and purposeful activity and it was clearly the case that she was at her best when she had human contact and things to do. However, it was also evident she that she found night time and other times when she was locked in her cell especially difficult. It is regrettable
that, at times, she was locked up for too long. In particular, she found the lockdowns over the period of Easter and the Royal Wedding, which preceded her death, very testing. On the night of her death she was also agitated by being locked down earlier than usual as a result of another prisoner’s death that same evening. It is possible, given her fragile mental health, that this affected her. “The investigation also found that Frances was able to access a non-prescribed antidepressant while in prison that, combined with her prescribed medication, may have affected her mood at the time of her death. I am therefore encouraged by the South Eastern Health and Social Care Trust’s commitment to review arrangements for the prescription and supervision of medication. Furthermore, as a result of this investigation, and other death in custody reports of the Prisoner Ombudsman, the Trust has now reviewed the provision of mental health arrangements in all Northern Ireland prisons.”

Mrs McCabe added: “It was also the case that Frances experienced a number of additional stress factors prior to her death. In particular, her two infant children were being fostered and she was upset that her sentence would be much longer than she had anticipated. It is also to note that the investigation found evidence that Frances was bullied when it was believed that she had told prison staff that she had seen an officer kiss an inmate. However, whilst it is not possible to say what impact this had on Frances’ already fragile mental health, an examination of all the related evidence suggests that it is unlikely that bullying by other inmates was a direct cause of her death at the time when it occurred.”