Irish Penal Reform Trust

Death in Custody Investigation Reports published

20th January 2020

On 8th January 2020, four Office of the Inspector of Prisons Death in Custody Investigation Reports were published by the Department of Justice and Equality. Three of the reports related to deaths that occurred in 2018, and one in 2019. The Inspector of Prisons investigates all deaths that occur in prison custody and also deaths that occur within one month of release from prison. Three reports related to deaths that occurred while the individual was on Reviewable Temporary Release (RTR) from custody.

The Irish Prison Service has responded to the Inspector’s recommendations in Action Plans published alongside the reports. IPRT strongly welcomes this development. IPRT previously recommended that the Irish Prison Service should publish progress reports towards the implementation of recommendations made by the Inspector. (See PIPS 2019, Action 25.1 p.88 and PIPS 2018, Action 25.2 p.88).

IPRT is clear that investigations into deaths occuring 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.

The Inspector outlined a number of recommendations in the case of Mr A, who was pronounced dead in his cell on the 10th January 2018 in Mountjoy prison. Overnight checks had not been conducted every hour in line with Standard Operating Procedures on the night preceding his death. His death went unnoticed both when an officer unlocked his cell for breakfast, and again when the cell was unlocked for the morning. Mr A was found by two fellow prisoners who raised the alarm. While the Inspector does not discuss the cause of death in her report, Mr A had been on medication for a debilitating medical condition.

Recommendations of the report by the Inspector of Prisons included:

  1. When officers are unlocking cells they should verbally communicate with the prisoners and ensure they receive a verbal response back in order to verify that the prisoner is not in need of medical attention. The IPS have stated that the implementation of this recommendation is ‘ongoing’ in their Action Plan relating to the Death of Mr A 2018.
  2. Monitoring of prisoners need to be improved and should be conducted in line with the IPS Standard Operating Procedures. New standard operating procedures were introduced in April 2019 by the IPS to address this issue.
  3. Disciplinary action should be taken where prison officers are found to have been negligent in their duty of checking prisoners in their cells. The IPS have stated that the status of their actions to address this recommendation is ‘complete’.
  4. All hand-over of duties should be recorded in the Night Journal by the Night Guard and signed off at the end of the tour of duty by the Supervising Officer. The IPS stated that implementation of this recommendation is complete.

In the case of Mr N, who died on the 15th October 2018 while on Reviewable Temporary Release (RTR) from Castlerea, the Inspector made one recommendation.

Recommendation of the report:

  1. The IPS should review the procedures of notifying An Garda Síochána of individuals granted RTR and ensure that they are implemented – Common practice at Castlerea was found to differ from IPS standard procedure. The IPS have classified the implementation of this recommendation as ongoing in their Action Plan relating to the death of Mr N 2018.

In the cases of Ms M, who died on the 26th July 2018 while on RTR from the Dóchas Centre, and Mr E, who died on 25th October 2019 while on RTR from Cork, no recommendations were made. In Ms M’s case, the next of kin were concerned that Ms M had been released to ease overcrowding, and she might have been able to received drug treatment had she remained in custody. In Mr E’s case, the next of kin were critical of the availability of illicit drugs in prison.

Read more:

Respect for rights in the penal system with prison as a last resort.



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