Prisoner Ombudsman publishes report into the death of a prisoner

Published on March 16 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 Emmett Cassidy was 28 years old when he died in hospital on 11 December 2018 following his transfer from Maghaberry Prison where he had been found unresponsive in his cell on 07 December 2018. Prison Service and Prison Healthcare staff successfully performed Cardiopulmonary Resuscitation (CPR) at the scene before Mr Cassidy was taken to hospital. An inquest is pending.

Mr Cassidy was a vulnerable young man who had many problems. His case is the third case the Ombudsman examined in 2018 which, while it found that Prison Service and Prison Healthcare had followed processes and procedures in place, lacked a means of connecting a series of individual incidents which could have led to a better understanding and response to Mr Cassidy's specific needs.

The Independent Clinical Reviewer, Professor Jenny Shaw, concluded that Mr Cassidy's death could not have been predicted with any certainty and although there were missed opportunities in his care, these would not have prevented his death.

Commenting on the report the Prisoner Ombudsman said:

"This investigation underlines the need for an important discussion about how the needs of vulnerable people like Mr Cassidy can be better managed in prison. I have previously raised these issues, in four cases, with the Department of Health and the Department of Justice. It is my view that innovative thinking and proposals are required about how engagement with people such as Mr Cassidy could be done differently to improve their lives, keep them safe and reduce the risk of them reoffending."

Dr Carroll welcomed the recommendations made in the recent RQIA report on vulnerable prisoners:

"Following on from The Review of Services for Vulnerable Persons Detained in Northern Ireland Prisons, RQIA October 2021, I am hopeful that new methods of information gathering and a new approach to needs assessment, envisioned in that report, are likely to provide the bedrock to develop more effective responses to individuals like Mr Cassidy. The proposed new assessment in particular is an opportunity to collate information from a number of sources and it is critical that this opportunity is not missed."

"In light of the challenges Mr Cassidy faced in his life, I again welcome the robust recommendations RQIA have made and the 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."

Dr Carroll expressed her appreciation to Mr Cassidy's family for their engagement with the investigation:

"I am conscious of the families who have lost a loved one while in custody and today, in particular, my thoughts are with Mr Cassidy's family. I am grateful to them for their contribution to this investigation and I appreciate their patience. I was privileged to meet Mr Cassidy's mother and listen as she shared her cherished memories of her son. Mr Cassidy was a compassionate young man who, as a teenager, had decided he would give hope to others after his death, by donating his organs.

"There is significant learning from this investigation, similar to other investigations, one published last month, about how the needs of people like Mr Cassidy can be better identified and managed in prison. I will continue to bring my concerns to those who can make improvement. Services to prisoners, aimed at the safety of individuals and which will lead to a safer society, must not be obscured by current financial constraints."

"I express my sincere condolences to Mr Cassidy's family and hope that this investigation and the 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.

This report contains one recommendation that community records should be reviewed before a patient is discharged from the mental health team caseload, which was not accepted.