Published on September 28 2015

The Prisoner Ombudsman for Northern Ireland today published an investigation report into the death of a released prisoner, Mr H, in September 2014. He had been released from Maghaberry Prison at the end of July due to an inoperable brain tumour.

This investigation found that several prison officers and nurses showed compassion for Mr H while he was in prison. He was not always compliant with the care that was offered and it is possible that his attempts to manipulate the medication which was prescribed did not assist his diagnosis. Treatment was also delayed when he did not attend a hospital Accident & Emergency Department.

The clinical reviewer recognised that some of Mr H’s care was very good, in particular his mental health assessments. However four opportunities to diagnose his tumour were missed and care plans were not initiated when he became dehydrated and malnourished. Although earlier diagnosis would not have changed the final outcome, opportunities for an extended life expectancy and a reduction in his distress through earlier palliative care could have been provided.

There were other findings which were not in accordance with best medical practice:

  • A lack of urgency when Mr H presented with new neurological symptoms;
  • Poor sharing of information by Healthcare staff who attended Mr H’s review meetings;
  • Lack of a co-ordinated follow-up after Mr H did not attend hospital;
  • Lack of involvement by doctors during the July holiday period;
  • Poor recording.

The report makes fifteen recommendations for improvement, all of which have been accepted by the SEHSCT and the NIPS.  Some of these are procedural, but a gap in clinical leadership is again noted at Maghaberry Prison.  One recommendation was previously made to, and accepted by the SEHSCT, in February 2012.

The SEHSCT accepted all of the recommendations of this report, stating they are committed to implementing improvements as a result of the lessons learned from all investigations. The NIPS said it is determined to use this report to strengthen systems already in operation throughout Northern Ireland’s prisons.

Prisoner Ombudsman Tom McGonigle, in expressing sympathy to the next of kin, said “This report again highlights the need for someone to actively take charge and manage the first line clinical care of patients in prison, where families are less able to assist or advocate on their behalf. The fact that we also published a report last week which raised virtually identical issues, reaffirms the need for the prison healthcare reform project to provide improved diagnoses and better palliative care for the terminally ill.”

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. For further information see
2.  In line with the Prisoner Ombudsman’s Terms of Reference a copy of this report has been sent to the Coroners Service for Northern Ireland.
3. The Prisoner Ombudsman aims to provide the facts of the case and publicise all material that is necessary to serve the public interest. This is balanced against legal obligations in respect of data protection and privacy, and next of kin views are therefore important when publication is being considered. In this case the next of kin have requested that their privacy be respected. Media enquiries should be directed to their solicitor, Katie McAllister on 028 9023 8007.