Prisoner Ombudsman publishes report into self-harm by Mr Sean Lynch

Published on September 13 2016

A report of the Prisoner Ombudsman’s investigation into Mr Lynch’s self-harm in Maghaberry Prison in June 2014 was published today.

The self-harm that Sean Lynch inflicted over a three day period was extreme and shocking. It followed deterioration of his mental health in the community and increasingly bizarre behaviour in prison.

Although a detailed Forensic Medical Officer’s assessment, which suggested formal psychiatric assessment was an “absolute necessity,” was sent to Maghaberry, Mr Lynch was treated as a routine referral. It took two weeks for him to see a psychiatrist, when he was diagnosed with a drug-induced psychosis. Our clinical reviewer said problems may have been compounded by the fact that there was an eight day delay in administering an increased dosage of medication that was prescribed.

The default approach for vulnerable prisoners - the interagency Supporting Prisoner at Risk (SPAR) process was initiated. However it was never designed to care for someone as challenging as Mr Lynch. While efforts were made to comply with the letter of the process, the spirit was completely missed. Various aspects of the NIPS policy for using observation cells were also deficient and there were also indications that Mr Lynch was treated less favourably at outside hospitals because he was a prisoner.

Numerous NIPS and the SEHSCT personnel were involved, but nobody took overall responsibility for managing him, either as a patient or as a vulnerable prisoner. Events moved faster than the official reaction, and his increasingly bizarre and violent crises were met by short-term responses which included several moves of location and placements in observation cells with anti-ligature clothing. A Transfer Direction Order to a secure healthcare setting was considered but the necessary assessment did not take place in time.

A contemporary, independent assessment by a priest is informative: he said “His condition is beyond anything the officers can cope with.”

It is clear that Mr Lynch faked symptoms on some occasions and this led certain NIPS officers to believe he was being manipulative. This belief, which was also partly caused by insufficient awareness of his mental illness, impacted negatively upon his management and care.

The escalation in Mr Lynch’s self-destructive behaviour required treatment at outside hospitals. His conduct was so challenging that he had to be restrained and tranquilised, and he seriously assaulted a prison officer. He inflicted an 8cm cut to his groin, allegedly with a piece of broken flask which he found after moving into a new cell. However this cannot be confirmed as the implement was never sought nor found.

Much of Mr Lynch’s main self-harm episode - he rendered himself blind and extended his groin injury - on 5th June was directly observed by prison officers. Although they complied with a strict interpretation of Governor’s Orders which require intervention if a situation is “life-threatening,” Mr Lynch did not meet the definition. It seems remarkable that the officers felt it was neither necessary nor appropriate to enter his cell to prevent him from self-harming further. Their duty of care was trumped by security concerns that appear to have had little basis in reality.

We make 63 recommendations for improvement, of which 11 have previously been made to, and accepted by the NIPS. Five recommendations have previously been made to, and accepted by the SEHSCT.

Ombudsman Tom McGonigle said “This dreadful sequence of self-harming highlights the challenges of caring for severely mentally-ill people in prison. The key messages from this investigation are the need for someone to take prompt and effective control when a prisoner/patient’s mental health is deteriorating rapidly; and for improved assessment and information-sharing at the point when people go into prison.”

Media contact

McCann Public Relations, Telephone: 02890 666322
Maria McCann: 07802934246 or Natalie Mackin: 07974935855

Notes to editors

1. The Prisoner Ombudsman’s current Terms of Reference authorise the Office to investigate serious self-harm incidents in prison custody when requested to do so by the Northern Ireland Prison Service. For further information see

2. The Ombudsman aims to provide the facts of the case and publish all material that is necessary to serve the public interest. This is balanced against legal obligations in respect of data protection and privacy for everyone concerned, and their views are therefore taken into account when publication is being considered. Mr Lynch and his family indicated they are content for the full findings of this investigation to be published.

3. Mr Lynch has requested that media enquiries for him should be directed to his solicitor, Kevin Casey of Mc Cartney Casey Solicitors on 02871288888