Prisoner Ombudsman publishes report into a Death in Custody

Published on February 22 2023

The Prisoner Ombudsman for Northern Ireland, Dr Lesley Carroll, has today published the findings of an investigation into the death of an individual in custody at Magilligan Prison.

Mr Gavin Mawhinney was 27 years old when he died on 04 February 2019 at The Royal Victoria Hospital following treatment at Causeway and Antrim Hospitals. Mr Mawhinney was transferred from Magilligan Prison to Causeway Hospital on 29 December 2018.

The cause of Mr Mawhinney's death is a matter for the Coroner. The Prisoner Ombudsman examines the circumstances surrounding a death in custody and builds a narrative of events including, as far as possible, answers to questions raised by the next of kin of the deceased. The Prisoner Ombudsman's report will inform the inquest, which is pending.

Mr Mawhinney was committed to custody at Maghaberry Prison on 11 Novebmer 2017 following a period of mental ill health. He was transferred to Magilligan Prison on 26 November 2018, 2 months before his death.

Mr Mawhinney was a committed father of 4 children and enjoyed visits from his wider family circle and friends. He found his transfer to Magilligan Prison difficult, as he feared he would not have visitors.

On 28 December 2018, the day before Prison Officers found him unresponsive in his cell, Mr Mawhinney received a letter that caused him distress. He was taken to Causeway Hospital that same night.

The Prisoner Ombudsman commissioned an independent clinical review to examine how healthcare was provided to Mr Mawhinney during his time in custody. Consultant Forensic Psychiatrist, Professor Jenny Shaw, carried it out.*

Following investigations the Prisoner Ombudsman found nothing recorded over the 2 months Mr Mawhinney was at Magilligan Prison to raise concerns indicating that how he was cared for affected his actions on 29 December 2018.

The Prisoner Ombudsman noted that 6 months earlier, on 01 July 2018, while in Maghaberry Prison, Mr Mawhinney had received an upsetting letter that triggered self-harming actions and at that time, he was placed on 30-minute observations in line with the "The Supporting Prisoners At Risk" SPAR process.

The Ombudsman recommended a review of how information about individuals in custody is provided to staff to ensure effective support to each individual in custody and stated it should include any information about triggers and stressors.

Furthermore, it was recommended that gathering such information should be a matter for both Prison Officers and Healthcare in Prison Staff** as an integral part of their shared responsibility for the care of those in custody. The Ombudsman highlighted the fact that the recently updated SPAR process, SPAR Evolution, is due to be reviewed and advised that improvements can be applied in light of any learning.

The Prisoner Ombudsman also recommended a review of and, where possible, an update of information provided about individuals in custody when they are transferred between prisons to assist those individuals in orientating themselves to their new surroundings and regime.

The Prisoner Ombudsman's third recommendation was concerned with family contact, about more responsive family contact arrangements, recommending that consideration be given to a named contact, or contacts, who would be the primary mechanism for communication with a family.

Concluding her Report Dr Carroll said:

"I offer my sincere condolences to Mr Mawhinney's family on their sad and painful loss. I hope this report provides information to address some of the questions they raised and explains events leading up to his death. The learning, expressed in recommendations, will, I hope bring some comfort and confidence to those who have family members in custody."