Death in Custody Investigation Report published for a death occurring on 2 October 2021

26th January 2024

On 26 January 2024, an Office of the Inspector of Prisons Death in Custody Investigation Report was published by the Department of Justice and Equality. The report is related to a death that occurred on 2 October 2021 while the individual (Mr. G, 2021) was in custody at Cork Prison. The Inspector of Prisons investigates all deaths that occur in prison custody and also deaths that occur within one month of release from prison.

IPRT welcomes the eight recommendations outlined by the Inspector in the case of Mr G, who was pronounced dead in his cell on 2 October 2021 in Cork prison.

The Irish Prison Service (IPS) has responded to the Inspector’s recommendations by accepting all the recommendations made and publishing a supporting IPS Action Plan alongside the report. Since 2020, action plans that make recommendations for change have been published alongside any death in custody investigation reports (as recommended by IPRT in previous editions of PIPS). In these action plans, the IPS outlines progress toward implementation of the OIP’s recommendation(s), including assigning responsibility to specific actors and a timeline for completion. PIPS 2022 echoes previous recommendations made, that the Irish Prison Service should publish progress reports towards the implementation of recommendations made by the Inspector. (See PIPS 2022, Action 25 p.69). IPRT welcomed the roll-out of the OIP investigations recommendation monitoring database, updated by OIP and IPS, which allows the public to track progress of recommendation over time.

IPRT is clear that investigations into deaths occurring in prison custody must be prompt to ensure that any systemic issues are identified and addressed in order to prevent potential future deaths. IPRT remains concerned about delays in publishing these reports, which play an important preventive and improvement role. (See PIPS 2022, Standard 25, p.68)

In the case of Mr G (2021), inadequate volume on the Cell Call Alarm and Emergency Bell, and obstructed cell alarm lights resulted in a delayed response of over 30-35 minutes after the calls were made. It was also found that CCTV footage does not corroborate all of the journal entries by officers in relation to checks on the deceased. There were also concerning issues raised by a family member, including difficulties in accessing support information after the death occurred.

Following the passing of Mr. G, a Governor’s Order was put in place by Governor which called for the following;

(a) Removed the options to turn down or mute the volume on Cell Call handsets;

(b) Required the ACO to check the cell call system daily on each landing and record same in their daily reports, which are to be reviewed by the Chief Officer;

(c) ACO must check the cell call system in the Control Room and record the check in their daily reports, which are to be reviewed by the Chief Officer;

(d) To fit monitoring devices to cell call systems in order to generate email alerts to management in the event of any cell call device being unplugged in the Class Offices and/or Control Room.

The OIP took the opportunity of its full unannounced inspection of Cork Prison in March/April 2023 to verify the operation in practice of these new procedures. It found that, while the call volume issue had been resolved, the location of the call lights outside the cells was unchanged; it remained the case that only those lights closest to the Class Office could be seen.

The Inspectorate’s team identified a further issue with the operation in practice of the call system at Cork Prison, leading the Chief Inspector to raise an Immediate Action Notification (IAN). The Director General immediately responded to this IAN, including by sending a technical team to Cork Prison on the following day. A further meeting took place between the Inspectorate’s team and a technical team from the IPS on 14 April 2023, during which the following mitigation measures were proposed: Installation of new high visibility call light boards in class offices; Re-calibration of the cell call telephone system to resolve the issue of one unanswered call blocking all others; Enhanced monitoring of cell call response times.

The eight recommendations outlined by the Inspector in the case of Mr G, who was pronounced dead in his cell on 2 October 2021 in Cork prison, are as follows:

1. Irish Prison Service should ensure that the ‘volume control’ on all emergency activation devices in the Class Office and Control Room across the prison estate be locked to an audible volume which cannot be lowered or deactivated.
2. A Class Officer and an Assistant Class Officer should continuously observe the landing to which they are detailed to, inter alia, ensure prisoners are adequately supervised to ensure they do not require urgent attention.
3. Class Officers and management grades should ensure that the visibility of a landing is not obstructed by posters and/or notices displaced on the glass panel of a Class Office. It is recommended that Irish Prison Service HQ issue an instruction to this effect to all Prison Governors who should ensure implementation and compliance.
4. The Irish Prison Service consider the relocation of the Cell Call Activation light from its current position and place it towards the top of the cell door thereby eliminating any possible obstruction of a flashing light.
5. Consideration should be given to a review of the ‘Chaplaincy and Next of Kin Notification’ document to include guidance on the provision of general practical information to the NoK following a death in custody.
6. It is recommended that that an Office Notice be issued to all Prison Governors to remind them of the importance of adherence to the terms of the IPS ‘Critical Incident Reporting and Debriefing Procedures’ which provides for the holding of both a hot and cold debrief following a death in custody and for all staff involved in the incident to be encouraged/facilitated to attend briefing.
7. The Irish Prison Service should ensure that staff understand the importance of accurate records and the consequences of creating an inaccurate record/report of their duty. Regular audits should be carried out by line management to ensure compliance. A similar recommendation has been made in the past in Mr. A 2012, Mr. H 2014 and Mr. I 2018.
8. It is recommended that Prison Officers be reminded of their obligation under Prison Rule 87(1)(b) which requires them to examine equipment in their area of responsibility and report any defects which could compromise good order, safe or secure custody or health and safety.

Read the full Inspection report. 

See the IPS Action Plan.