Prisoner Ombudsman publishes report into the death of a prisoner

Published on June 23 2021

The Prisoner Ombudsman for Northern Ireland, Dr Lesley Carroll, has today published the findings of an investigation into the death of Mr Fred McClenaghan.

Mr McClenaghan who was 57 years old died in Hospital on 21st October 2018 following his collapse at Magilligan Prison earlier that day.

His post-mortem found that his death was caused by a subarachnoid haemorrhage due to a ruptured aneurysm.

Mr McClenaghan had collapsed in prison five days earlier on the 16th October. The Prisoner Ombudsman's report considered whether or not his referral to hospital was appropriate and if there was any impact on the outcome for Mr McClenaghan and would it have been any different if a hospital referral had been made sooner.

The Prisoner Ombudsman commissioned an independent clinical review and expert opinion from a consultant neurosurgeon to examine Mr McClenaghan's healthcare while in custody and to ensure he was treated as he should have been. Both reviews agreed that an earlier referral was unlikely to have resulted in a different outcome.

This matter was at the core of family concerns and the Prisoner Ombudsman accepts the very significant challenges for families who are separated from their loved ones, particularly as they near the end of their lives, and is very conscious of the desire families have to ensure their loved ones are not alone.

Speaking about the publication of her report Dr Carroll said:

"I hope it is of some comfort to the family to know that Mr McClenaghan received an appropriate standard of care, that his friends were nearby when he collapsed and that it was possible for them to spend some time with him while he was in hospital.

I offer my sincere condolences to Mr McClenaghan's family on their sad loss and in the knowledge that the experience of loss can be long-lasting. I hope this report provides information to address some of the questions they raised and explains events leading up to Mr McClenaghan's death.

I am grateful to the Prison Service, the South Eastern Health and Social Care Trust and the medical experts for their contributions to this investigation. Others have helped in the information gathering process and to them I also extend my gratitude.

My recommendation that the Assistant Director of Healthcare in Prison should introduce a policy or expand existing policy to provide guidance on the processes to be followed in the event of a sudden collapse has been accepted. A Joint Procedure for Responding to a Collapsed Adult/Patient requiring Cardiopulmonary Resuscitation in Prisons" was finalised in May 2020."