Investigation report into the Death in Custody of Mark Charles Maginnis

Published on March 21 2012

The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today published her report into the death of 40-year-old Mark Charles Maginnis, who died of features consistent with septicaemia due to infection of foot ulcers while in the custody of Maghaberry Prison on Monday 25 October 2010.

Mr Maginnis was diagnosed as an insulin dependant Type 1 diabetic at the age of nine years old. During his time in custody Mr Maginnis’ condition was carefully monitored by members of Maghaberry’s healthcare team, however the investigation found that recurrent problems arose as a result of Mr Maginnis’ non compliance with his treatment programme. The investigation found that prison staff tried to impress on Mr Maginnis on a number of occasions the importance of adhering to compliance with his treatment and his diet plan.

The investigation found a number of possible explanations for Mr Maginnis’ non-cooperation with his care.  Whilst he had never been diagnosed with a mental illness, he did experience symptoms of low mood and anxiety and problems in his personality organisation.  He had been in prison since 1991 and had panic attacks when he was required to attend outside hospital appointments. His approach to his illness was also affected by his experiences before he came into prison and his belief that his diabetes would eventually lead to blindness and amputation.  

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

The Prisoner Ombudsman found that:

• Despite written medical confirmation that Mr Maginnis was exempt from providing voluntary drug tests due to his diabetes, he was still subjected to regime demotions when he refused to provide a sample, which made him feel down and, on occasions, led him to self harm;

• Whilst it was subsequently agreed that he should not be demoted to a basic prison regime, this did in fact occur and Mr Maginnis was inappropriately prohibited from progressing to an enhanced regime with greater prisoner privileges;

• When Mr Maginnis took an overdose in March 2007, the protocol for the opening of a ‘Prisoner at Risk’ (PAR) booklet was not followed or the issue raised at a “safer custody” meeting;

• On 30 November 2009, whilst Mr Maginnis was on a ‘Supporting Prisoner’s at Risk’ (SPAR) booklet (formally known as PAR), he was notified that he had been demoted to a basic regime following a refusal to provide a drug test and his television was removed. Three hours later Mr Maginnis self harmed saying that he had been “pushed too far.” No consideration, as required by Prison Service policy, was given to the appropriateness of removing Mr Maginnis’ television at the time;

• Healthcare staff generally believed that Mr Maginnis had the capacity to refuse medical treatment, however there was no formal ‘Capacity Assessment’ carried out and recorded when Mr Maginnis refused important medical intervention;

• There is no clear supervisory/review process in place for the long term use of therapies.

Releasing the report, Mrs McCabe said:

“The investigation found that Mr Maginnis’ failure to attend some medical appointments, along with his poor management of his diabetes, regrettably had a detrimental affect on the health of his feet. It appears that Mr Maginnis’ condition deteriorated very rapidly on the morning of 25 October 2010 and his death, occurring as it did, was not expected.  There were quite complex reasons why Mr Maginnis may not have cooperated with his care, one of which was that after more than 19 years in prison, he found the outside world quite daunting when he needed to attend hospital.  He also suffered, at times, from low mood and anxiety and was fearful of the long term consequences of his illness.” 

“Whilst Mr Maginnis overall care was found to be consistent with that he would have received in the community, a small number of concerns were identified, particularly in respect of the Prison Service’s response to his difficulty in providing samples for drugs testing for medical reasons.” 

Mrs McCabe added: “These issues of concern must be now be addressed by the Northern Ireland Prison Service and the South Eastern Health and Social Care Trust as part of their programmes for change.”