Prison authorities not giving 'sufficient attention' to circumstances around vulnerable inmate deaths

Prison authorities not giving 'sufficient attention' to circumstances around vulnerable inmate deaths

The Inspector of Prisons said it is repeating recommendations on the deaths of vulnerable inmates “over and over again” but that prison authorities do not appear to be taking steps to prevent such fatalities recurring.

In a hard-hitting attack, the new inspector said the failure of the Irish Prison Service to enforce recommendations in successive Death in Custody reports meant that they were not “receiving sufficient attention”.

Inspector Patricia Gilheaney said there should be “zero tolerance” of cases where there is a failure to carry out the required observations of vulnerable inmates and that “appropriate disciplinary action” should be taken.

Responding, the IPS said the director general Caron McCaffrey was concerned at the points raised and that an action plan was in place to “resolve all” of the Inspector's recommendations.

Ms Gilheaney made her comments in a foreword to an inspection report conducted by acting inspector Helen Casey.

Ms Casey, a principal officer in the watchdog, examined the death of a 31-year-old inmate in Limerick Prison (identified only as Prisoner G) after he was found with a ligature around his neck in his cell on 6 May 2017.

    Key points in Ms Casey's report reveal:

  • It was the Prisoner G's first time in jail and he had only been in custody for nine days;
  • He was on remand in custody awaiting to face charges at the time of his death;
  • His next of kin (Ms A) said he had been in the psychiatric unit of University Hospital Limerick for five weeks immediately prior to his committal to prison, had showed “suicidal ideation” and was on prescribed medication;
  • Ms A said Prisoner G had told her in phone conversations that he did not get his medication (though he did get is soon after) and said she had experienced “considerable difficulty” in trying to book a visit;
  • Prisoner G was on Special Observation – meaning checks by staff every 15 minutes;
  • An examination of CCTV by a Chief Officer in the prison, on behalf of the Inspector, found that five prison officers checked on the inmate but that the variation between checks was 28 minutes to 2.54 hours;
  • During the period the man was locked in his cell he should have been checked 39 times, but the Chief Officer found only nine checks were conducted;
  • While the Chief Officer had initially saved the CCTV footage and supplied a written report to the Inspector, the footage could not be located by IT staff at IPS HQ and it may have been “accidentally deleted”;

The Inspector's report said: “There was no explanation provided by the five officers as to why the cell checks were not every 15 minutes.”

It said this was despite the office making nine attempts seeking such explanations.

The examination by the Chief Officer of the CCTV footage found that the variation between the nine checks were 34 minutes, 28 minutes, 2.54 hours, 56 minutes, 49 minutes, 1.49 hours, 57 minutes, 1.09hours, 57 minutes, 1.14 hours and 54 minutes.

The report said the local chair of the Prison Officers' Association, responding on behalf of the officers, said they were waiting to view the CCTV footage in order to enable them to give a full and accurate account of their interactions with Prisoner G but were hampered by not being allowed to see the footage.

The report said the prison governor stated that staff were unable to conduct 15-minute checks due to other operational demands on the night.

The Governor said staff were dealing with an incident elsewhere for over two hours. The Governor said there were 10 prisoners on special observations (spl obs) and nine further committals, requiring 768 checks and 2,520 general checks.

Prison authorities not giving 'sufficient attention' to circumstances around vulnerable inmate deaths

“This number of spl obs and general checks is physically impossible to complete while detailing with an incident for over two hours on D2,” the Governor said.

In her foreword, Ms Gilheaney said her office had been investigating deaths in custody since 2012.

She said that “over the past six years” the office had identified incidences of a failure to adhere to “special observations”, which according to IPS policies and procedures, required checks on assigned inmates every 15 minutes.

She said the investigation into the death of Prisoner G found that the special observations were not implemented.

“It is clear that the controls in place were inadequate. It is noted that similar recommendations have been made in Death in Custody reports over and over again and therefore it leads me to conclude that they have not been receiving sufficient attention,” Ms Gilheaney said.

She said there should be “zero tolerance in instances where there is failure to carry out the required observations and appropriate disciplinary action taken”.

She said the failure to record and/or retain CCTV footage should be considered “a very serious matter” and said the office had raised this issue before.

Ms Gilheaney said failure to adhere to the law was of “particular concern”.

She said it was of “serious concern” that despite successive calls to take action to prevent more deaths that the “opportunity to prevent recurrence of similar deaths does not appear to be sufficiently addressed”.

Prison authorities not giving 'sufficient attention' to circumstances around vulnerable inmate deaths

She welcomed measures the IPS Director General had pledged on foot of receiving a draft report in December 2018 to implement the recommendations.

In a statement, the IPS said the Inspector had raised “a number of points which are of concern” to the Director General, who had “put in place an action plan to resolve all of the recommendations”.

It said the measures have been introduced “to ensure compliance” with the 15-minute checks requirement.

It said landing lighting had been modified to ensure “visibility of staff” conducting checks on CCTV and prison management were now able to review all night duty CCTV footage.

It said the DG had written to all staff highlighting their responsibilities and obligations and instructed management to take “all necessary action” to ensure compliance.

It said new guidelines for the imposition of disciplinary sanctions would be published internally “in the coming days”.

Fíona Ní Chinnéide of the Irish Penal Reform Trust said: "Investigations into deaths in prison custody are required to be prompt in order to identify any systemic issues and avoid potential future deaths. The failure by the Irish Prison Service to secure evidence is of particularly grave concern, as is the 18-month timeline for completion of the initial investigation report.

“It is critical now that the Minister for Justice and Equality ensures the Inspectorate has the resources to fulfill its important function, and that the Inspector's recommendations are implemented in full across the prison estate."

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