Prisoner Ombudsman publishes report into the death of an individual in custody at Maghaberry Prison

Published on March 08 2023

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

Mr Stewart was 38 years old when he died in Maghaberry Prison on 17 May 2017, having been admitted to custody on 15 March 2017.

When Mr Stewart was remanded into custody, the committal Nurse recorded a disclosure made by him to the PSNI that he had cut himself once 15 years earlier and that he had no current thoughts of self-harm. It is for the coroner to finally decide, at inquest, whether Mr Stewart's death was due to self-harm.

At the time of his death Mr Stewart had spent 9 weeks in prison. During that time, he had concerns regarding his oral health, and he attended a dentist on 3 occasions.

A Prison Officer found Mr Stewart collapsed in his cell in the early hours of 17 May 2017 and immediately alerted healthcare staff, who tried to resuscitate him. Paramedics attended the scene and continued with attempts at resuscitation but ultimately, they had to confirm Mr Stewart's death.

The independent Clinical Reviewer, Ms Jane Mackenzie, concluded that on the balance of probabilities Mr Stewart's death could not have been predicted or prevented. She was satisfied that his physical and mental health screening, monitoring and delivery of care were appropriate to meet Mr Stewart's clinical needs at that time.

The Prisoner Ombudsman agreed with the independent clinical reviewer's findings.

The Prisoner Ombudsman made 3 recommendations, 2 for the Prison Service in relation to checking the condition of a cell and preserving the scene of a death in custody. The third recommendation was for the South Eastern Health and Social Care Trust regarding up to date CPR training for staff. All recommendations were accepted and the Prisoner Ombudsman confirms they have been implemented.

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

"I am conscious that the feelings of loss and grief continue for Mr Stewart's family and that they have outstanding questions, even after a significant passage of time. It is important that the Coroner concludes this case at inquest and confirms cause of death. I offer my sincere condolences to them on their sad loss and hope that my report and the inquest will provide them with the information they need."

Dr Carroll also extended thanks to the Northern Ireland Prison Service, South Eastern Health and Social Care Trust and the Clinical Reviewer for their contributions to the investigation.

The investigation into Mr Stewart's death was concluded in 2019, however publication was delayed at the request of Mr Stewart's family. Further action was taken by the Prisoner Ombudsman following engagement with Mr Stewart's family and this report has been amended in light of those discussions and the passage of time.