Prisoner Ombudsman publishes report into the death of a prisoner

Published on March 05 2020

Mr Johnston was found dead on 4th August 2017 in his cell at Magilligan prison. His death was drug related and it did not appear that he intended to take his own life. He was 27 years old when he died.

The report makes seven recommendations for improved practice to the Northern Ireland Prison Service (the Prison Service) and the South Eastern Health and Social Care Trust (the Trust).

Speaking about the publication of her report Dr Lesley Carroll said: “I offer my sincere condolences to Paul’s mother and father, his family and wider circle of friends. The death of a loved one is always difficult. The fact that a death occurs in prison custody has particular difficulties given the loss experienced by the family and also the wider prison community.

“I am concerned about the devastating impact of substance misuse and poor mental health which resulted in Paul’s untimely death. Sadly, we know this is not an issue confined to those who live and work within prisons. This problem requires a broad response taking the whole life of communities into account and targeted at both prevention, by addressing the root causes of behaviours that can result in people losing their lives in these circumstances, and also response so that people can access effective services when they most need them. Prisons should play their part in an overarching strategy but the challenge is systemic and society-wide.”

The key learning point for the Prison Service, the Trust and their partner agencies arising from my investigation is that people with vulnerabilities need to be more effectively identified in order that they may be kept safe while in custody.

While some aspects of Mr Johnston’s care could have been better, I cannot say with any certainty that these would have changed what happened.

“Nonetheless my investigation identified important learnings which could help prevent a death in future. This includes consideration of:

  • what is taken into account when people transfer from one prison to another;
  • the effectiveness of substance withdrawal monitoring;
  • the response when some-one stops taking their medication;
  • the adoption of technology to reduce the supply of drugs coming into prison.”

A copy of the report is available from 00.01 5th March 2020

Media contact
McCann Public Relations, Telephone: 02890 666322
Maria McCann: 07802934246

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 Johnston’s family indicated they are content for the full findings of this investigation to be published and for his name to be included in the report.

3. Dr Carroll took up the post of Prisoner Ombudsman on 1st March 2019.

4. The following recommendations for improvement were made to the Northern Ireland Prison Service (NIPS) and the South Eastern Health and Social Care Trust (SEHSCT):

  • Managing vulnerable prisoners: The Prison Service and the Trust, together with their partner agencies, should review the assessment of risk and management of those presenting with complex case histories and are difficult to engage in services to ascertain if a case formulation model is workable in a prison environment or can be built into existing models (p20).
  • Managing vulnerable prisoners: The Governor should review Magilligan’s Vulnerable Persons’ Policy to ensure it meets the purpose for which it is intended (p21).
  • Inter-prison transfers: The Prison Service and Trust should discuss and agree the approach to transferring prisoners who are being monitored for withdrawal when a transfer to another prison is being considered so that any clinical risks can be appropriately managed (p21).
  • Withdrawal monitoring: The Trust should ensure that alcohol withdrawal monitoring is completed once commenced (p22).
  • Medication: The Trust should ensure that if it is identified that a patient is not taking their prescribed medication, they will be offered an appointment with a GP to discuss this and the outcome documented in the patient’s record. The Trust should ensure that any unused medication is disposed of (p22).
  • Record-keeping: The Trust should put in place arrangements to audit health care records to monitor compliance with national and local standards (p23).
  • Reducing the supply of drugs: The Prison Service should continue to explore new developments in the use of search technology and equipment to better detect drugs concealed in a person (p26).