Prisoner Ombudsman Publishes Report Into A Serious Adverse Incident
Published on November 21 2025
The Prisoner Ombudsman has today published a report relating to a Serious Adverse Incident which took place on 23 September 2022 while a prisoner was being transferred from Antrim Court to Maghaberry Prison.
During the transfer, through CCTV, Prisoner Officers observed the prisoner had placed the seat belt around their neck. The vehicle was immediately stopped, the prisoner’s pulse checked, and they were moved to an observation cell. As the journey continued, the prisoner became unresponsive. Upon arrival at Maghaberry Prison, Healthcare in Prison staff attended and began treatment. Paramedics were called, who took over treatment, and the prisoner was transferred to hospital. The prisoner was returned to Maghaberry Prison on 24 September and placed on a SPAR Evo care plan.
On 2 October 2022, the Office of the Prisoner Ombudsman for Northern Ireland was invited by the Northern Ireland Prison Service to investigate this Serious Adverse Incident. This investigation looked at the circumstances surrounding the incident, including health and clinical matters, and how it was handled by Prison Officers and Healthcare in Prison staff.
The Prisoner Ombudsman’s report notes this critical event took place in a short time frame, and the officers acted in line with good practice. He also noted the Trust’s actions following the incident in identifying learnings and implementing actions.
NI Prisoner Ombudsman, Darrin Jones, said, “I would like to thank all NIPS and HiP staff involved for the response taken in relation to this incident, which resulted in a prisoner’s life being saved without long-term harm. This incident occurred in a short time frame during a transfer to prison, which highlights the importance of professionalism by prison staff at all times.”