Investigation report into the death in custody of Patrick Duffy

Published on June 13 2012

The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today published her report into the death of 49-year-old Patrick Duffy, who died of ‘poisoning by dihydrocodeine, diazepam and chlordiazepoxide’ whilst in the custody of Maghaberry Prison on Thursday 23 June 2011.

Mr Duffy was committed on remand into the custody of Maghaberry Prison on 20 April 2011. A review of Mr Duffy’s GP records showed that he had a long and complex medical history and a number of background risk factors that indicated an increased risk of abuse of medication and self-harm in custody.

The investigation found that, at the time of his committal, Mr Duffy was issued all of the medication he advised he had been taking in the community on a weekly in-possession basis. No contact was made with his GP to confirm his prescription and no request was made for his community medical records at this or any other time during his committal. No consideration was given to referring Mr Duffy to mental health services.

During his time in custody Mr Duffy had two episodes of deliberate self-harm resulting in the opening of SPAR (Supporting Prisoners at Risk) booklets and periods of supervised swallow for the administration of his medication. Mr Duffy also failed a drugs test while in custody. He was, however, repeatedly assessed as being suitable to return to weekly in-possession of his medication up until the time of his death.

There was clear evidence that Mr Duffy was able to obtain non-prescribed substances. The day before he died, Mr Duffy was prescribed a week’s supply of 14 analgesic tablets, 14 antidepressants, 14 tablets for epilepsy and 21 tablets for a thyroid problem. At the time of his death, just two remaining tablets were found in his cell. The diazepam and chlordiazepoxide found in his blood were not prescribed.

Mr Duffy was due to attend court on the day of his death and was expected to get bail. His cell mate reported that Mr Duffy was looking forward to leaving prison to be with his partner and family. No evidence was found that Mr Duffy intended to die.

The investigation report points to 14 issues of concern requiring action by the Northern Ireland Prison Service and South Eastern Health and Social Care Trust relating to the management of Mr Duffy’s medication administration, his mental health management, access to non-prescribed drugs and trading of his medication. The Prison Service and South Eastern Health and Social Care Trust have given a commitment to address all of the areas of concern and details of progress made since Mr Duffy’s death are included in the report.

Releasing the report, Mrs McCabe said:

“This is yet another tragic warning of the importance of effectively addressing the use of drugs within prisons and further emphasises the need for a joined up approach to implementing the prison reform programme. It is fundamental that prescription medication is supplied safely with careful and continuous monitoring of any risks of misuse or particular vulnerabilities associated with the individual. A failure to do so only serves to compound the problems associated with the availability and use of illicit drugs. Mr Duffy’s self-referral to addiction services suggests that he recognised a problem with his dependence on drugs, yet in spite of his continuing self-harm and abuse of medication, appropriate consideration was never given to the possible need for Mr Duffy to be reviewed by a prison doctor or by the mental health team.

“To this end, the Prison Service needs to be much more effective in dealing with drug trading and misuse, in addition to the associated culture of bullying created by such practices. Curbing the supply of drugs is highly dependent upon reducing demand and it is therefore essential that greater priority is given to purposeful regimes and therapeutic interventions. In particular, the current six month waiting time for a first appointment with ADEPT (Alcohol and Drug Educational Programme and Training) services is entirely unsatisfactory. It is not to be underestimated that the implications of such insufficient provision are far reaching and could ultimately undermine prison reform through the resulting negative impacts on the intended role of the prison officer, the delivery of purposeful activity and the potential to achieve effective rehabilitation and resettlement.”

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.”