Prisoner Ombudsman Publishes Report into the Death of a Prisoner

Published on August 15 2017

A report of the Prisoner Ombudsman’s investigation into the death of Mr Laurynas Steponavicius in Maghaberry Prison was published today.

Mr Steponavicius, a Lithuanian national, was remanded to Maghaberry Prison on 5th January 2016. He was found hanging on 11th February and died 11 days later at an outside hospital, aged 23.

This was his first time in custody, and our clinical reviewer was satisfied he did not exhibit any evidence of mental illness or excessive distress during his first few days in Maghaberry.

Mr Steponavicius had asked to see Police officers while in prison and they visited him on the day before he died. He told them that he felt safer in Maghaberry than in the community.

Despite this assertion to police, he met with a Senior Prison Officer and a nurse the next day and requested a transfer to another cell. He was anxious as he had disclosed his meeting with the police to his cellmate, who was also his co-defendant. The Senior Officer promptly initiated the request for a transfer, but it did not happen prior to his death, just two hours after they spoke with him.

The Senior Prison Officer and nurse provided discrepant accounts about whether Mr Steponavicius disclosed suicidal ideation to them.

After he died it transpired that Mr Steponavicius had previously suggested to fellow Lithuanian prisoners and to his girlfriend that he was contemplating suicide; and that he had made an unsuccessful attempt about a week before he died. Unfortunately nobody passed this information on to prison officers or healthcare professionals because they did not believe he was serious.

As a young man in a foreign prison Mr Steponavicius was in a higher than average risk category. He also appeared to be stressed by the relationship with his girlfriend, and by his isolation as he did not have any visitors or contact with family during his time in Maghaberry.

Our clinical reviewer was satisfied that the resuscitation process was well-led and well- conducted by the Northern Ireland Prison Service and South Eastern Health and Social Care Trust staff when Mr Steponavicius was found.

This report makes four recommendations for improvement, all of which have been accepted. (See Notes to editors)

Prisoner Ombudsman Tom McGonigle said “This is a sad case of a young man who ended up in prison in another country, far from his family. He had prospects for bail but several matters were stressing him, some of which were not known to the authorities until after he died, and he felt he had no-one to turn to for support. I extend my sympathy to his next of kin for their untimely loss.”

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

Notes to editors
1. The Prisoner Ombudsman’s Terms of Reference require the Office to investigate all deaths in prison custody. 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 Steponavicius’ family indicated they are content for the full findings of this investigation to be published.
3. The following recommendations for improvement were made to the Northern Ireland Prison Service (NIPS) and the South Eastern Health and Social Care Trust (SEHSCT):


  • Foreign national prisoners should be allowed to make a free international call upon committal if their designated next of kin does not live locally.


  • The SEHSCT should ensure that smoking cessation support is developed in line with best practice, including a full range of medication and psychosocial treatments and regular monitoring of patients’ progress.
  • The SEHSCT should ensure that staff have an awareness of factors which put prisoners at higher risk of self-harm or suicide, and ensure they look beyond prisoners’ self-report.
  • The SEHSCT should ensure that they are satisfied that Agency staff have the necessary level of Supporting Prisoners at Risk (SPAR) training and that a record is made of such training.