Prisoner Ombudsman publishes report into the death of Mr Patrick Kelly in March 2015
Published on September 27 2016
A report of the Prisoner Ombudsman’s investigation into Mr Kelly’s death on 20th March 2015 was published today.
Patrick Kelly had been heavily dependent on medication for several years. When remanded to Maghaberry Prison he asked not to be allowed to retain his tablets as he was afraid he would take them all at once. Unfortunately his prophetic request was only briefly heeded. After four days on “supervised swallow” he was returned to “in-possession” status without any protective measures to mitigate the risk of overdosing. He appears to have hoarded his tablets, then used them to overdose and died two days later at outside hospital, aged 46.
The nurse who most probably took the decision to return Mr Kelly to holding his own medication asserted that she had no recollection of doing so.
Additional concerns that arose about medication management in this case included inconsistent prescribing practice, an eleven day delay in providing new prescriptions for Mr Kelly, and incorrect assumptions that his medication was being supplied, or taken as prescribed.
Both clinical reviewers whom my office retained considered Mr Kelly’s committal experiences in February 2015 were insufficient to keep him safe. They felt his overdose was foreseeable and one also concluded that his death was preventable.
There were other concerns about the committal process: while Mr Kelly’s health problems were highlighted in documents that accompanied him to Maghaberry, prison officers and nurses overlooked them and relied instead on his self-reports and immediate presentation. They did not recognise the significance of a Forensic Medical Officer’s assessment that he was at high risk of self-harm, nor share this information with colleagues.
The emergency response on 18th March was very good when Mr Kelly disclosed that he had overdosed.
Prisoner Ombudsman Tom McGonigle offered his sympathy to Mr Kelly’s family and said “This poignant case has provided considerable learning about medication management in prison. It is particularly difficult for his family to accept that Mr Kelly died from an overdose of his own medication after having asked not be allowed to hold it because he recognised the risks.”
The Ombudsman added “I must yet again stress the importance of Prison and Healthcare personnel paying heed to information they receive from external agencies when someone arrives into prison, and sharing that information with all who need to know. The report makes 21 recommendations which I trust will be used to improve the prospects for prisoners in future.”
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Notes to editors
1. The Prisoner Ombudsman’s Terms of Reference require the Office to investigate all deaths in prison custody. For further information see Terms of Reference for Investigation of deaths in prison custody.
2. The Ombudsman aims to provide the facts of the case and publish all material that is necessary to serve the public interest. This is balanced against legal obligations in respect of data protection and privacy for everyone concerned, and their views are therefore taken into account when publication is being considered. Mr Kelly’s family indicated they are content for the full findings of this investigation to be published.
3. Mr Kelly’s family have requested that media enquiries be directed to their solicitor, Conor Sally of Logan & Corry Solicitors on 028 82250400.