Investigation report into the death in custody of Samuel Carson

Published on November 20 2012

The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today published her report into the death of 19-year-old Samuel Carson, who died by suicide while in the custody of Hydebank Wood Prison and Young Offenders Centre on Wednesday 4 May 2011.

Samuel was initially charged with a number of sexual offences and was remanded in custody on 6 March 2010. The Public Prosecution Service (PPS) subsequently withdrew charges of rape and making indecent images in November 2010. The case for the remaining charges, against which Samuel pleaded his innocence, was never heard because of his death. The investigation was made aware that all remaining charges against Samuel’s co-accused were later withdrawn when the PPS offered no evidence.

The investigation identified a number of factors that may have contributed to an increased risk of suicide in custody. In particular, the investigation found clear evidence that, during his time in custody, Samuel experienced sustained bullying by other prisoners related to the alleged sexual offences for which he was on remand and the belief of other prisoners that he was “a tout”. The investigation also identified issues in connection with Samuel’s mental healthcare treatment in prison and his medication.

The report points to twenty eight 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: “Regrettably, this investigation has again highlighted, 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. Although there is evidence that, on numerous occasions, prison officers themselves recognised, or were alerted to, prolonged verbal and physical bullying of Samuel, little was done to address the actions of the perpetrators. There cannot be any acceptance that bullying in prisons is inevitable or will be tolerated. A failure to robustly address bullying within prisons can lead to all too tragic consequences.

“The investigation also highlighted inadequate monitoring of Samuel’s mental health. In particular, in the weeks prior to his death, Samuel was prescribed an antidepressant drug known to pose an increased risk of suicidal ideation in young males during the initial stages of its use. Although the investigation concluded that there was no reason to suggest Samuel was inappropriately prescribed this medication, the necessary monitoring of his well being during this time was inadequate.”
Mrs McCabe added: “It is also the case that circumstances outside of the Prison Service’s control added to Samuel’s anxiety. Although Samuel was eligible for bail on a number of occasions during his time in custody, the PSNI had advised of paramilitary threats on the life of Samuel and suitable accommodation was unable to be found. Samuel was also aware that the history of his relationship with his girlfriend could result in his youngest child being taken into the care of Social Services, if the couple remained in contact.”