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

Published on March 15 2023

Daniel McConville had been in Maghaberry Prison for 70 days when he was found unresponsive in his cell. Despite attempts to resuscitate him he died at the scene on 30 August 2018. He was 22 years old. An inquest is pending.

During his time in prison Mr McConville was managed under the Supporting People At Risk (SPAR) process which helps staff identify symptoms or behaviours that suggest a person may be at risk of harming themselves.

Mr McConville, who had frequent periods in custody, had complex needs including a history of self-harm, substance misuse, depression, Attention Deficit Hyperactivity Disorder (ADHD) and learning difficulty.

Commenting on the key learnings from the Investigation the Prisoner Ombudsman, Dr Lesley Carroll said:

"I am concerned that the needs of those who face multiple challenges in their lives, including multiple low level health diagnoses, could be better addressed while they are in custody.

"The challenge is not only to better assess need but also, and importantly, to develop long-term care plans and to ensure those care plans are consistent and persistent throughout the treatment of any individual and that, if required, they are shared with Community services on an individual's release from custody.

"I sympathise with the concerns expressed by Mr McConville's mother who said that throughout her son's early years and while in custody no one appeared to put together the elements influencing his behaviour. She felt her son's needs could have been managed more constructively if this had happened."

The Ombudsman noted the number of cell moves Mr McConville experienced and questioned if this was appropriate for the rehabilitation of an individual with ADHD, learning difficulties and wider mental health issues and whether it was appropriate for a young man with anxiety and depression to manage his own medication.

Supporting the approach taken by Regulation Quality and Improvement Authority (RQIA) Dr Carroll warned that inadequate resources could delay progress:

"The RQIA's approach, which is to establish a needs profile for individual's in custody is to be encouraged. However, I am concerned that the prison regime does not currently have adequate resources to provide the responsiveness required to support an individual like Mr McConville and this lack of resources will delay the required development work."

The Ombudsman highlighted her previous actions following 2 other similar cases when she wrote to the Director, Reducing Reoffending, Department of Justice in August 2020 when she set out the issues of concern, and asked for them to be considered by the Departmental Health and Justice Improving Health within Criminal Justice Implementation Group:

"I recognise not all of these issues are the sole responsibility of the Prison Service or the Trust to action. It would require collaboration with a wide range of agencies and organisations involved in providing care and support to people engaging with the criminal justice system and community services."

The Prisoner Ombudsman made 5 recommendations: two in relation to ADHD with regard to identification, training and a needs review; a third regarding documentation of requests for the relocation of individuals in custody who are being supported with a care plan, designed according to risk, and two further recommendations in relation to protocols around information flow between the Prison Service and PSNI in respect of ongoing criminal investigations and the management of the activation of cell's fire protection water sprinkler systems.

Concluding her Report Dr Carroll expressed gratitude to the Prison Service, the Trust and the independent Clinical Reviewers for their contributions to her investigation:

"I offer my sincere condolences to Mr McConville's family on their tragic loss. I hope this report provides information to address some of the concerns they raised. i wish to acknowledge that the McConville family do not believe their son would have been able to plan and carry out the actions that led to his death. They make this judgement based on what they knew of Mr McConville and the impact his ADHD and learning difficulties had on how he approached and experienced life. While I have found that Mr McConville's care was within standards, I am also convinced that there is considerable work to be done to ensure that the notion of rehabilitation is a reality for young men such as Mr McConville.