Investigation report into the near death of Mr C

Published on April 30 2013

The Prisoner Ombudsman for Northern Ireland, Pauline McCabe, today published the Office’s first ‘near death’ investigation into the attempted suicide of a male prisoner.

The prisoner, referred to as ‘Mr C’ in the Prisoner Ombudsman’s investigation report, made an attempt to die by suicide on Sunday 19 February 2012 while in the custody of Maghaberry Prison. As a result of the incident, Mr C now has a complex physical disability and cognitive impairment caused by severe brain injury, including an inability to speak and communicate basic needs.

The investigation found that Mr C had a number of background risk factors that indicated an increased risk of suicide in custody. This included a past psychiatric history, previous alcohol abuse, the recent bereavement of his partner, and distress caused by his two young children being in care.  During his time in custody, Mr C had episodes of self-harming, suicidal ideas, and had also become increasingly anxious about his personal safety.

The Prisoner Ombudsman identified 44 areas of concern as a result of this investigation, including:

• The approach to caring for vulnerable prisoners, particularly in connection with the quality of care planning and care coordination;
• The response to Mr C’s anxiety about his safety;
• The assessment of fitness for cellular confinement and the treatment of cellular confinement where prisoners are known to be very vulnerable;
• Communication and sharing of information relevant to the assessment of care needs and development of appropriate care plans;
• Arrangements for assessing and delivering mental health care.

Releasing the report, Mrs McCabe said:

“The investigation found that the implementation of Supporting Prisoner at Risk protocols was, in general, to a higher standard than has been observed in other investigations.  This undoubtedly reflects the efforts that have been made by the Northern Ireland Prison Service and South Eastern Health and Social Care Trust to improve the arrangements for protecting prisoners at risk of self-harm.

“Nevertheless, it is the case that, despite this prisoner’s history and significant number of self-harm risk factors while in custody, he was confined to cell for long periods with very limited human contact. This poses fundamental questions about the effectiveness of the Prison Service and the Trust’s approach to managing vulnerable prisoners.  In particular, this investigation has raised concerns about the extent to which current procedures for dealing with vulnerable prisoners, even where conscientiously applied, actually deliver an appropriate level of care. It should never be the case that a ‘box ticking’ approach undermines the ability of individual officers and healthcare staff to apply common sense and compassion to prisoner care and, as such, there is a clear need for a further review of how vulnerable prisoners are dealt with.”

Mrs McCabe added: “This investigation has emphasised the importance of near death investigations in highlighting issues of concern and providing learning and service improvement opportunities for both the Prison Service and the South Eastern Health and Social Care Trust.  I have always considered the Prison Service’s criteria for triggering a near death investigation to be unduly restrictive and I believe that any serious incident resulting in permanent physical and/or mental impairment should warrant investigation by the Prisoner Ombudsman. I am therefore pleased that the Director General of the Prison Service has now given a commitment to review this.”