Investigation Report Into The Death of a Prisoner

Published on November 26 2013

The Prisoner Ombudsman for Northern Ireland today published an investigation report into the death of a prisoner who died shortly after he returned home from prison.

A post mortem found Mr D had died of Pneumonia.  However toxicology tests indicated the presence of prescribed and non-prescribed drugs which may have contributed to his death through supressing respiration.

As a sufferer of chronic leg and back pain Mr D was treated with high doses of painkillers through repeat prescriptions over a prolonged period of time.  He was given responsibility for self-administering his medicines during his time in prison.

It has been the practice of the Prisoner Ombudsman to identify matters of concern that require action to improve standards of prisoner care and help to prevent serious incidents or deaths in the future.  In the case of Mr D, 14 matters of concern have been identified.   Several of these matters, including the availability and management of drugs in prisons, were identified in previous Death in Custody reports. 

A detailed account of the evidence examined during the investigation has been included in the main body of the report.  This is particularly to assist Mr D’s family, the South Eastern Health and Social Care Trust (SEHSCT), the Northern Ireland Prison Service and the Coroners Service for Northern Ireland.  There is a comprehensive summary for readers who do not wish to consider all of the investigative detail.

Media contact:

  • McCann Public Relations, Telephone: 02890 666322
  • Maria McCann: 07802934246 or Natalie Mackin: 07974935855

Notes to editors:

1. The Prisoner Ombudsman’s Terms of Reference require the Office to investigate all deaths in prison custody since September 2005. Please see for further information.

2.  In line with the Prisoner Ombudsman’s Terms of Reference a copy of this report has also been sent to the Coroner.

3. Publication of Reports
Death in Custody reports are published on the Prisoner Ombudsman’s website.  Subject to family views and data protection requirements, reports will be redacted and anonymised in order to preserve the privacy of the deceased prisoner and their family.  The Prisoner Ombudsman strives to ensure that readers can establish the facts of the case, and that all necessary information is shared in the public interest.