Investigation Report into the Death In Custody of Stephen Doran

Published on March 10 2010

The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today made a total of eight recommendations following her investigation into the death in custody of Stephen Patrick Doran, aged 69, at Maghaberry Prison on June 6, 2008.

Releasing her Investigation Report, Mrs McCabe said: “My primary aims are to inform the Coroner of my findings and to make recommendations which will help prevent similar deaths in future at Maghaberry or elsewhere in the Northern Ireland Prison Service.

“Mr Doran was in a poor state of health when he was committed to Maghaberry and he was immediately transferred to the prison health care centre, where he died four days later.”

“Following a thorough investigation informed by the opinion of a highly qualified independent medical expert, I am making eight recommendations relating to the care of seriously ill people in prison. These concern a revision of practice in the recording systems, making observations, hospital admission criteria, and the capture of prior medical history.”

The Prisoner Ombudsman added: “My recommendations have all been accepted by the Northern Ireland Prison Service and the South Eastern Health and Social Care Trust, who accepted that the standard of care and treatment of Mr Doran fell short of what was normally expected.”

“The Trust has put a Service Improvement Board in place in Maghaberry to develop and drive forward the quality of health services in prison.”

Further media inquiries should be directed to Janet Devlin or Vicki Caddy at ASG on 028 9080 2000 or by email to or

Notes to editors:

The Prisoner Ombudsman terms of reference require her to investigate all deaths in prison custody since September 2005.
The Prisoner Ombudsman made a commitment when she took up post in September 2008 to publish all Death in Custody investigation reports. Copies of all reports published to date can be found at
When the Office was given this additional role, no extra resources were provided, however the current Prisoner Ombudsman secured some additional resources in summer 2009 and is currently working through a backlog of investigations.
In line with the Prisoner Ombudsman Terms of Reference a copy of the Report will also be sent to the Coroner.
Investigations are ongoing into a further 10 deaths in prison custody.