Prisoner Ombudsman Publishes Report Into A Death In Custody
Published on May 21 2026
The Prisoner Ombudsman has today published a report relating to the death of Mr Orhan Kibar, who died aged 47 on 30 May 2023 at Maghaberry Prison. The Prisoner Ombudsman for Northern Ireland is responsible for providing an independent and impartial investigation into deaths in prison custody in Northern Ireland.
Mr Kibar was committed to Maghaberry Prison on 05 April 2019 and had served four years of a 16-year sentence at the time of his death. He had a complex medical history, including bipolar affective disorder, Type 2 diabetes, hypertension, hypercholesterolaemia and atrial fibrillation.
On 30 May 2023, Mr Kibar was found unresponsive in his cell at Maghaberry Prison. CPR was commenced by Healthcare in Prison (HiP) and Northern Ireland Prison Service (NIPS) staff and continued until paramedics from the Northern Ireland Ambulance Service arrived. Life was pronounced extinct at 09:16. The cause of death was recorded as intracerebral haemorrhage and hypertension, and was determined to have been from natural causes.
The Prisoner Ombudsman undertook an investigation into the circumstances surrounding Mr Kibar’s death which examined the care and treatment provided by NIPS and Healthcare in Prison (HiP), and that provided by the South Eastern Health and Social Care Trust, during Mr Kibar’s time in custody.
The investigation found that Mr Kibar received healthcare at least equivalent to that available in the community and that there was evidence of regular multidisciplinary support, appropriate mental health care, preventative healthcare interventions and ongoing monitoring of his physical health conditions.
The report identified one recommendation for the South Eastern Health and Social Care Trust relating to resuscitation protocols and decision-making, including ensuring staff responding to emergencies are clinically competent and confident in determining when CPR should not be commenced or should be discontinued.
The report also highlighted serious concerns regarding the failure to carry out and accurately record overnight prisoner safety checks on the night of Mr Kibar’s death. CCTV reviewed during the investigation showed that some checks recorded in official records had not in fact been carried out. NIPS has confirmed that the matter has been referred to its Professional Standards Unit for further investigation.
Speaking on the publication of the report into Mr Kibar’s death, the Prisoner Ombudsman, Darrin Jones, said:
“I offer my condolences to Mr Kibar’s family on their loss and I hope this report provides clarity around the care he received while in custody.”
“This investigation found that Mr Kibar received healthcare at least equivalent to that available in the community, including appropriate mental health support, multidisciplinary care and preventative healthcare interventions throughout his time in custody.”
“I am concerned at the failure to carry out and accurately record overnight safety checks on the night of Mr Kibar’s death. It is essential that prisoner safety checks are completed properly and recorded accurately to ensure prisoner wellbeing and maintain confidence in custodial processes.”
“It is important that opportunities for learning are identified and acted upon to support continued improvement in both healthcare and operational practices within the prison environment.”
“I also thank all of those who contributed to this investigation.”