Irish Penal Reform Trust

Never again: Irish Prison Service must set and implement safe custody limits now to avoid potential future tragedies - IPRT

1st May 2014

The Irish Prison Service must set and maintain safe custody limits, aligned with the recommendations by the Inspector of Prisons, to ensure that potential future tragedies can be avoided; the protection of vulnerable prisoners must be a priority; and until such time as full integration with the HSE is achieved, all prisoners requiring mental health treatment should be assessed for diversion into services outside of the prison estate.

IPRT was responding to The Report of the Commission of Investigation into the Death of Gary Douch, which was published today (1st May 2014) exactly 7 years and 9 months after the young man’s brutal death in Mountjoy Prison on 1st August 2006. There is a duty on the State by virtue of Article 2 of the European Convention on Human Rights to provide a prompt investigation, into Mr. Douch’s death. IPRT strongly believes that investigations into deaths in custody must be prompt so that any systemic failures that led to the death of a prisoner can be addressed, and potential future deaths can be avoided. In this case, the family of Gary Douch has waited almost eight years for this report: by any standards such a delay is completely unacceptable.

System failures, severe overcrowding, inadequate oversight, and inaccurate recording and sharing of critical information were among the litany of failures identified by the Commission. The Commission found “reckless disregard for the health and safety” of prisoners and staff alike in the decision taken by Cloverhill Prison to transfer a prisoner who had been assessed by a Central Mental Hospital treatment psychiatrist as “acutely psychotic” to Mountjoy Prison. The State failed in its duty to provide safe custody to 21-year old prisoner Gary Douch.

Responding today, IPRT Executive Director Deirdre Malone said:

“After seven years of waiting, we welcome the publishing of this comprehensive and detailed report. We agree with the overall findings of its author Gráinne McMorrow SC that on reading about the tragic and untimely death of this young man it is “impossible not to conclude that flawed management , poor decision-making, lack of accountability and a culture of inattentiveness prevailed throughout the system.”

“While there have been significant improvements in the system since the time of Gary Douch’s death in 2006, there is plenty of room for further progress. Overcrowding persists: just last night (30 April 2014) Cork Prison held 231 prisoners, which means it is running at 133% of the maximum capacity of 173 recommended by the Inspector of Prisons. This report provides a valuable opportunity to learn lessons for the future - we particularly hope that the Strategic Review Group on Mental Health will strongly consider the 34 specific recommendations on mental health care and treatment in Irish prisons contained in the report.”

“Our deepest sympathies extend to the family of Gary Douch. If there can be any positive legacy at all from this tragedy then it should be that concrete and effective changes will be swiftly introduced that will prevent any other mother from losing her child in this way.”

On publication of this report, IPRT has restated a number of previous calls on the Minister for Justice, and the Irish Prison Service, attached below.

For all media enquiries or interview with Deirdre Malone, IPRT Executive Director, please contact: Fíona on 087 181 2990087 181 2990


1              On August 1st 2006, 21-year-old Gary Douch was unlawfully killed in Mountjoy Prison in a holding cell he shared with six others, one of whom was mentally ill. A commission of investigation was established in May 2007, headed by Gráinne McMorrow SC, with its report expected by the end of 2007. There were a number of factors leading to delays in the report’s publication, including delays by the State in furnishing McMorrow with documents and information. On 1 May 2014, the report was finally published. It is available here:

2.       Overcrowding

Improvements have been made to Mountjoy Prison, but chronic overcrowding exists in 6 of the other 14 prisons, including in Castlerea, Cloverhill, and Cork prisons, along with Limerick female prison and the Dóchas Centre. Last night (30 April 2014), Castlerea Prison held 361 prisoners, which means it was running at 120% of the maximum capacity of 300 recommended by the Inspector of Prisons; Cork Prison held 231 prisoners, which means it is running at 133% of the maximum capacity of 173 recommended by the Inspector of Prisons. Overcrowding is unsafe and dangerous for prisoners and staff alike. Therefore IPRT calls on the Irish Prison Service to set safe custody limits for each prison, in line with the Inspector of Prisons’ recommendations, and these limits must never be breached.

3. Mentally-ill prisoners:

The IPRT Submission on Mental Health and Criminal Justice 2012 stated:

  • Where appropriate, those with mental illness should be diverted away from the criminal justice system and should be treated within a community setting.
  • Transparent and proper recording procedures on mental health should be implemented by the Irish Prison Service; if a prisoner is transferred, these records should also be transferred with immediate effect. 
  • IPRT continues to campaign for the elimination of the practice of detaining mentally-ill prisoners in observation cells. Instead vulnerable care units should be established with 24 hour supervision by a psychiatric nurse.
  • Overcrowding and the elimination of ‘slopping out’ must to be addressed in order to enhance and facilitate positive mental health in the Irish prison system.
  • All prison staff should receive awareness training regarding suicide and self-harm prevention in prisons.
  • Additional spaces should be made available in psychiatric hospitals for the diversion of mentally-ill offenders.        
  • The mental health Prison in-reach and Court Liaison Service should be expanded across the entire prison estate.
  • IPRT advocates for the principle of equivalence of healthcare in the prison context should be equal to that in the community setting.
  • IPRT advocates that, where appropriate, mentally-ill offenders should be imprisoned as a last resort.

4. IPRT position on Investigations of Deaths in Prison Custody

In section 2.2 of the IPRT Position Paper 7: Complaints, Monitoring and Inspection in Prisons (see here) IPRT clearly sets out the requirements of independent investigations into deaths in prison custody, including:

  1. the investigation must be undertaken on the State’s own initiative
  2. it has to be capable of leading to a determination of responsibility and the punishment of those responsible;
  3. the investigation has to be independent both institutionally and in practice;
  4. it must be prompt;
  5. the investigation has to allow for sufficient public scrutiny to ensure accountability;
  6. and the next-of-kin has to be allowed to participate in the process.

IPRT has previously expressed concern that the cumulative effect of the law and practice concerning investigations into deaths in custody in Ireland falls short of the requirements of the ECHR, particularly in relation to the involvement of the next-of-kin in the process; the ability to establish responsibility, if any, of the Irish Prison Service; and the ability to examine the wider context in which the death took place, or any systemic issues.

See IPRT Position Paper 7: Complaints, Monitoring and Inspection in Prisons

IPRT believes the State has failed to meet its obligations under the European Convention of Human Rights to deliver a prompt investigation into Mr. Douch’s death. Significant delays in providing information to the Commission of Inquiry contributed to these setbacks. Investigations should be prompt so that any systemic failures that led to the death of a prisoner can be addressed, and potential future deaths can be avoided.

Since 2012, the death of any prisoner in the custody of the Irish Prison Service is subject to an independent investigation by the Inspector of Prisons; these reports are made public, and have been published in a timely fashion. As part of the Programme for Government, the Minister committed to introducing legislation to strengthen the powers of the Inspector of Prison, but that the proposed legislation has not yet been published. IPRT calls on the Minister to bring forward this legislation at the earliest opportunity.

5.  Irish Penal Reform Trust (IPRT) |

IPRT is Ireland's leading non-governmental organisation campaigning for the rights of everyone in prison and the progressive reform of Irish penal policy, with prison as a last resort.

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



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