Investigation Report Into The Death of A Prisoner

Published on April 29 2014

The Prisoner Ombudsman for Northern Ireland today published an investigation report into the death of a prisoner, “Mr E,” who died by hanging at Maghaberry Prison.

Mr E was recognised as vulnerable due to the nature of his offences, and was therefore accommodated on a landing for prisoners who might be at risk from others.  He had no known history of self-harm or suicide attempts.

The investigation identified several areas of concern:
A communication breakdown meant that medications for depression and anxiety, which were prescribed in the community, discontinued once Mr E entered prison;  
Cues such as Mr E’s personal efforts to highlight his anxieties, and an apparent deterioration in his mental health, were missed;
He was not referred for psychiatric assessment, despite fulfilling criteria that indicated this ought to have been done; 
Arrangements that existed to help vulnerable prisoners, such as the Prisoner Safety and Support Team and the Supporting Prisoners at Risk process were not implemented; and
Staff had inadequate training in the NIPS Anti-Bullying Strategy.

Thirteen recommendations are made to improve standards of prisoner care and help prevent serious incidents or deaths in the future. One of these, involving meaningful handovers when staff change shift, has been 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 E’s family, the South Eastern Health and Social Care Trust, 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.

Prisoner Ombudsman Tom McGonigle said “Although Maghaberry had the necessary arrangements in place to support vulnerable prisoners, Mr E was not identified as needing them. The NIPS and SEHSCT have accepted all our recommendations and made subsequent improvements that aim to improve the care of vulnerable prisoners in the future.” 

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 Coroners Service for Northern Ireland.

3. Publication of Reports
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.  This is balanced against our legal obligations in respect of data protection and privacy, and we therefore take careful account of next of kin views when considering publication.  If publishing, we offer to anonymise reports and redact dates or other identifying information, in order to preserve the privacy of a deceased prisoner and their family.