Prisoner Ombudsman Publishes Report into the Death of Mr Bernard Law

Published on September 26 2019

The Prisoner Ombudsman for Northern Ireland Dr Lesley Carroll has today published the findings of an investigation into the death in custody of Mr Bernard Law.

Mr Law was 44 years old when he died at Magilligan Prison on 25th March 2017. He had been placed in custody on 4th September 2015 at Maghaberry Prison and transferred to Magilligan Prison later that month. He died of natural causes.

Commenting on the findings Dr Carroll said:

“Any death is difficult to deal with but a death in custody is all the more difficult for families given the separation they already experience when a loved one is taken into custody.

“I am conscious of the overwhelming sense of loss experienced by Mr Law’s family whose unstinting care for him during his life is notable. I acknowledge their devastating sense of loss. I have tried to answer as many of the family’s questions as possible but appreciate that they are not completely satisfied with the findings of the investigation and the information provided.

“Following my investigation I have made three recommendations to the NI Prison Service, all of which have been accepted. None of these would have made a difference to Mr Law’s situation: they would not have saved his life. But their implementation will contribute to an improved system of support for vulnerable prisoners.”

Mr Law had been engaged with community mental healthcare services before he was admitted to custody. His healthcare in prison was, therefore, an important aspect of how he was treated in custody. A clinical review, to assess provision of health care for Mr Law, concluded that his care was equivalent to, and in some instances better than, the care he would have received in the community. In addition the clinical reviewer noted some areas of good practice and these are highlighted in the report.

The Prisoner Ombudsman concluded that there were no areas of concern identified as contributing to Mr Law’s death.


  1. The objectives for Prisoner Ombudsman investigations of deaths in custody are to:
  • Establish the circumstances and events surrounding the death, including the care provided by the NIPS;
  • Examine any relevant healthcare issues and assess the clinical care provided by the South Eastern Health and Social Care Trust
  • Ensure that the prisoner’s family have an opportunity to raise any concerns they may have, and take these into account in the investigation; and
  • Assist the Coroner’s investigative obligation under Article 2 of the European Convention on Human Rights, by ensuring as far as possible that the full facts are brought to light and any relevant failing is exposed, any commendable practices is identified, and any lessons from the death are learned.
  1. The Prisoner Ombudsman meets with the family early in the investigative process to establish if they have any concerns and again when the final report is due for publication to discuss findings.
  2. Throughout the investigation representatives of the Prisoner Ombudsman’s Office liaise with the family, or their representative.
  3. Clinical reviews are commissioned from independent reviewers, based in England, to establish the facts about a prisoner’s healthcare while in custody and identify concerns, should there be any.
  4. The NI Prison Service and South Eastern Health and Social Care Trust are required to co-operate with the investigation.
  5. In this case, the main issues addressed in this investigation with regard to Mr Law’s care are:
  • If the medical records provided by Mr Law’s legal representative at court informed his care in Maghaberry and Magilligan prisons;
  • The level of care and treatment he generally received while in prison, and;
  • If it was appropriate that Mr Law was accommodated in a single cell at the time of his death.