Prisoner Ombudsman publishes report into the death of a prisoner

Published on February 09 2022

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

Mr U died in hospital in 2018 following his transfer from Maghaberry Prison where he had been found unresponsive in his cell, 4 days after he was committed into custody. Prison Service and Trust* staff successfully resuscitated him at the scene before he was taken to hospital. An inquest is pending.

In the last 16 years of his life Mr U had been in custody 45 times.

The longest period he had been in custody was approximately one and a half years.

In the last year of his life Mr U had been in custody 5 times and had been released approximately a month prior to his most recent committal to Maghaberry Prison.

The Independent Clinical reviewer, Dr Adrian Grounds, was satisfied that Mr U had been managed in accordance with procedures. Dr Grounds also identified the need for a more joined up assessment, taking an individual's history and experience into account, to effectively inform provision of care.

The Report found that there was concern about Mr U's behaviour and wellbeing on the night before he was found unresponsive. Prison Service staff attended to him overnight in order to keep him safe.

Dr Grounds was satisfied the actions taken by Prison Service staff in response to his behaviour was reasonable. He was also of the opinion that Mr U required clinical assessment with an immediate out-of-hours mental health assessment and potentially medication. However, the report states that it is not possible to say with certainty that any different course of action could have altered the sad outcome in this case.

Nevertheless, the Ombudsman's Report identifed the need for Prison Service and Trust staff to collaborate in a situation such as this and the need to develop mechanisms for joint informed assessment of prisoners. In particular, the Ombudsman noted the need to share healthcare information to inform a prisoner's care in the interests of their safety.

During the investigation of Mr U's death, the Ombudsman raised her concerns with both the Prison Service and the Trust and sought assurances that the relevant Government Departments would give attention to mental healthcare provision in prisons. The Ombudsman noted that The 'Review of Services for Vulnerable Persons Detained in Northern Ireland Prisons', RQIA October 2021, went some way to addressing her concerns.

Commenting on the report the Prisoner Ombudsman, Dr Lesley Carroll said:

"I welcome the RQIA review of services for vulnerable people in prison. They have made robust recommendations with a clear timetable for delivery. It is imperative that this work is completed without delay and that services involved remain open to further improvement to ensure the safety of those who are in custody.

"I am very conscious of the families who have lost a loved one while in custody and today, in particular, Mr U's family. I am grateful to them for their contribution to this investigation and I appreciate their patience.

"There is significant learning from this investigation both for the immediate services in prisons but also for the wider criminal justice system given Mr U's repeated admissions into custody for short periods of time when support from community services was interrupted rather than sustained.

"I express my sincere condolences to Mr U's family and hope that this investigation and outcomes from it will give confidence to those who have family members in custody."

Dr Carroll also extended thanks to the Prison Service, the Trust and the Clinical Reviewers for their contributions to the investigation.

*Healthcare in prisons is delivered by the South Eastern Health and Social Care Trust (The Trust)