Prison staff have been disciplined after CCTV disproved records that an inmate in Cork Prison was checked every 15 minutes in the hours before he was found dead in his cell.
Cork City Coroner's Court heard the detail today during the inquest into the death of David Blackwell, 52, in a cell in the prison's vulnerable person's unit (VPU) on Jan 2, 2017.
Inmates on that wing should be checked every 15 minutes. Initialled prison records indicated that the checks were done on Mr Blackwell. But CCTV footage later disproved the records and revealed long gaps when he wasn't checked, including one period of one hour and 47 minutes.
Following an investigation, including one by the Inspector of Prisons, prison staff were disciplined for shortfalls in duty and for failing to carry out checks, the prison's assistant governor, Liam Spacey told city coroner, Philip Comyn.
Mr Blackwell, who had been living in Kealkil, Bantry before his committal to prison in October 2016, had a history of psychiatric illness and drug and alcohol abuse.
On the afternoon of his death, medical orderly Ed Stack said he was concerned for Mr Blackwell's mental health and decided to transfer him to the VPU at around 4.45pm.
Acting chief officer, Ger Manley, said all inmates on the VPU should be checked every 15-minutes.
Nurse officer, Mick Byrne, reviewed Mr Blackwell in his cell at 5.45pm and said he was grabbing the air with his right hand and appeared to be in the midst of a psychotic relapse. Mr Byrne gave the prisoner a fast-acting anti-psychotic tablet and reviewed him in the cell at 6.20pm where he said Mr Blackwell appeared to be listening to the wall, and making writing gestures on the wall with his hands.
Mr Byrne told the inquest that he tried to take Mr Blackwell's vital signs but he didn't cooperate, was agitated and so he withdrew from the cell: "I knew him well. We had a good rapport. He got enjoyment from his delusions. He saw orbs and sometimes declined, as was his right, medication because when he took the meds, the orbs would disappear. He felt they were a company for him."
Nurse officer, Rosemary O'Donnell, lifted the flap of Mr Blackwell's cell door to check him at 7.19pm and said he appeared calm:
In his deposition, prison officer Tim Sexton, who was on duty on the VPU that night, said the 15 minute checks were performed and that when he checked on the inmate at 10.45pm, he saw him asleep on the floor, raise his head, and go back to sleep.
But the alarm was raised at 11.45pm when ACO Manley said instinct prompted him to check the cell. Staff found Mr Blackwell unresponsive on the floor. Despite medical attention, he was pronounced dead at the scene later. A post mortem established the cause of death as acute congestive cardiac failure.
Mr Comyn was shown initialled prison logs which indicated that the required 15 minute cell checks were performed. But CCTV footage showed just three checks between 7.25pm and 10.45pm.
Mr Sexton told the inquest that he was confused and upset when he gave his statement: “I have saved numerous suicides. This was the first time a prisoner died in my care."
Under questioning from Elizabeth O'Connell, SC, on behalf of Mr Blackwell's family, Mr Sexton said Mr Blackwell's name wasn't on his list of special observation inmates and that he had never been shown how to fill out the observations log sheet. He also said there was "possibly a lack of communication with night staff".
The jury returned a verdict of death due to natural causes and made no recommendations.