INVESTIGATION REPORT INTO THE DEATH OF A PRISONER
Published on October 14 2014
The Prisoner Ombudsman for Northern Ireland today published an investigation report into the death of a prisoner, Mr G, who died from natural causes at outside hospital on 14th August 2013, while on temporary release from Maghaberry Prison.
The Prison Service had released Mr G two days earlier, in order that he would not die in custody. This was a humane and compassionate gesture that benefitted him and his family.
He had a late and unexpected diagnosis just a fortnight previously, which came as a shock to him and his family. Mr G had a variety of pre-existing conditions and had been in pain from mid-July. The consultant physician in charge of
his care advised that his condition would have been progressing for a number of months.
While earlier transfer to outside hospital would have assisted his pain relief, and there were differing opinions about some aspects of Mr G’s medical care in prison, our clinical reviewer confirmed that a four day delay in sending him to hospital would not have made any difference to his prognosis.
The investigation has identified seven matters requiring improvement. Although they did not contribute to Mr G’s demise, they are important in relation to the future care of other prisoners. They include the review of prisoners’ medication upon committal, alcohol withdrawal assessments, nursing attendance to prisoners during the night, and the application of Prison Rule 27.
The NIPS have accepted the recommendations of this report, and said they have already been implemented. The South Eastern Health & Social Care Trust also accepted their recommendations, and advise that they have been reiterated to their staff, and will be considered at a Lessons Learned forum.
Prisoner Ombudsman Tom McGonigle, in expressing sympathy to the next of kin, said “While some things could have been done better, it is important that an independent investigation and clinical review conclude there was no possibility to achieve an alternative outcome for Mr G.”
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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 www.niprisonerombudsman.gov.uk/termsofreference.html 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. In this case Mr G, his next of kin were content that all the investigation details should be made public.