Inmate deaths lead to call for culture change

The concerns highlighted by two prison inspectors on proper records being kept by officers appears to be falling on deaf ears within the service, with the fear without a change from the culture of ‘cover your arse’, further deaths of vulnerable prisoners will occur, writes Joe Leogue

'Keep it short and cover your arse.’

It’s a phrase that leaps out from the page, particularly so when it appears in a report prepared by a statutory body.

In 2014, the late Judge Michael Reilly was concerned.

Cork Prison, where a prisoner died in January 2017

The Clonmel native was now seven years into his term as inspector of prisons, having served a distinguished career on the bench as a judge in both the District and Special Criminal Court.

During his time as prison inspector, the same significant problem arose time and time again, and no matter how many times he called for the issue to be addressed, it would present itself once more, as if his words were falling on deaf ears.

Vulnerable prisoners were dying — and the official prison records of the circumstances around their deaths were not true accounts of what happened in the prison that day.

Every time a prisoner died in custody, the prison inspector would investigate the circumstances around the death.

Judge Reilly’s job was not to determine the cause of death — that was for the coroner — but he was tasked with examining whether the prison staff followed all correct protocols at the time.

A trend, however, was emerging regarding vulnerable prisoners who required special observation — ‘special obs’ as they are known.

In many cases, such prisoners are recognised as having mental health problems, suicidal ideation, or a history of self-harm.

Protocols dictate that ‘special obs’ must be checked on every 15 minutes, and staff must record each check in a log book.

Judge Reilly, however, found repeated incidences where a check of CCTV footage from the day a ‘special obs’ prisoner died contradicted the entries in the log.

He highlighted the problem in his 2013/2014 annual report, published in August 2014.

There is a lack of appreciation in some quarters that accurate and truthful records must be kept,” he wrote.

“I must point out, at this juncture, that prison records are official records and it is a very serious matter to falsify official records. An example of this could be a statement to the effect that a prisoner on Special Observation had been checked in accordance with the procedures for the checking of such prisoners when in fact this may not have happened.

“Inspection bodies such as my office should be entitled to rely on the veracity of official records.”

Judge Reilly said he had been told that, in a number of prisons, the approach to record-keeping is to put “as little on paper as is necessary”.

In one investigation that I had sight of, an officer, in referring to report writing, is quoted as stating: ‘We are only trained on report writing in initial training and they tell you to ‘keep it short and cover your arse’,” he wrote.

The prison inspector has been tasked with preparing individual reports on deaths in custody since 2012.

Since then, 87 such reports have been published — and an analysis of these by the Irish Examiner has found that the reports into 12 deaths have raised concerns about deficiencies in the record keeping and the checking of prisoners.

Eleven of these 12 cases involved a vulnerable prisoner who was on special observation at the time of their death.

Fifteen such prisoners have died since 2012 — meaning the investigations into more than two-thirds of the deaths of vulnerable prisoners have raised concerns about checks and record keeping.

It is not a problem unique to any one prison — the 12 cases of concern occurred in Mountjoy, Cork, Limerick, Portlaoise, Cloverhill, and Wheatfield Prisons.

Mountjoy Prison

Judge Reilly died in November 2016, and Helen Casey assumed the role of inspector of prisons.

She found the same problems persisted, despite her predecessor’s warnings.

She noted how Judge Reilly had previously “highlighted failure by some staff to observe Standard Operating Procedures, inaccurate and at times misleading reports of incidents, poor record keeping and lack of supervision which, he found, resulted in operational deficiencies”.

She too, noted the same issues in her own findings.

Yet the problem persists.

Only last March, Ms Casey published a report on the death of ‘Prisoner A’ on January 3, 2017, in Cork Prison.

The 52-year-old married father, who was serving a six-month prison sentence, had received medical and psychiatric attention while in Cork Prison.

According to the medical observation cell bBook for the night he died, staff checked on the inmate every 15 minutes — as per protocol — from 4.30pm to 7.15pm, and again from 8pm to 11.15pm, before he was found unresponsive in his cell at 11.38pm.

The cell book said one thing — however, the cameras told another story.

Upon viewing CCTV footage from the prison, Ms Casey found six intervals where the prisoner was left unattended for more than 15 minutes on the night he died — the shortest of these being for more than half an hour.

The longest period during which the man was left unattended lasted one hour and 42 minutes.

“In examining the CCTV footage, it is clear that the deceased was not checked in accordance with the Standard Operating Procedure,” Ms Casey reported. “The Standard Operating Procedure [SOP] for Special Observation Prisoners, in Cork Prison, states that Special Observation Prisoners must be checked every 15 minutes.

The entries referring to checks on the deceased in the Medical Observation Cell Book… which is an official prison record… are misleading in content and but for the CCTV footage viewed, I would have accepted the written record as representing compliance with the relevant SOP.

“All prison personnel must appreciate that official documents must reflect the truth of actions taken by officers.

“Irish Prison Service Management should address poor record-keeping.

Governors should ensure that regular audits of all records are carried out to ensure compliance.

“Incomplete and inaccurate record keeping regularly feature as a finding in reports from this office as does this recommendation.”

If the concerns of the prison inspectors are falling on deaf ears within the prison service, they are certainly not being ignored elsewhere.

“In the inspectors’ reports, you can sense the growing frustration over a number of years,” Deirdre Malone, executive director of the Irish Penal Reform Trust (IPRT) told this paper.

“The reason that prisoners on ‘special obs’ are required to be checked on every 15 minutes is that they have already been identified as vulnerable.

So the prisons and the officers are already on notice that this is a person who is vulnerable for whatever reason, and that requires these checks to be performed and performed as per the Standard Operating Procedure in order to prevent issues like suicide and self-harm.

Ms Malone said the fact these deficiencies continue to happen ”is a cause for really significant concern”.

“The outcomes of these cases are the most serious of the most serious type, these are deaths in custody — people have lost their lives in custody,” she said.

“There is no option when you’re on special obs. There is no other option, to contact a family member, there is no option to ring an ambulance yourself, there is no option to ring a friend. You are entirely dependent on other people, namely officers, to look after you and when they don’t do that or when they don’t do their checks, the consequences can be of the most serious type, which they were in these cases.”

Ms Malone believes the fact that misleading official reports are repeatedly presented to the prison inspector “raises some fairly serious concerns about whether or not there is a culture or practice of obfuscating the truth”.

It’s certainly fair enough to draw a conclusion that there is a serious problem with practice when it comes to ensuring that checks are conducted regularly,” said Ms Malone.

“There are probably many officers who are doing the checks properly and tragedies are being prevented because those checks are happening properly and regularly and we don’t hear about them.

“But in terms of the regularity with which we are seeing this coming up in the reports of the inspector, I think we can say that this is certainly something that requires significant examination and analysis as to why, when it has been identified, that it is continuing.”

For the penal reform trust, that examination needs to determine whether this issue is a systemic failing or a cultural issue.

Ms Malone highlights prison overcrowding as one possible reason.

“That puts officers under unbelievable the pressure,” she said. “So if it is an issue that is not physically possible [to do all the necessary checks] because of the number of officers available, it would be very useful to know that.

“If it is a cultural issue, that people are simply not doing this as a matter of practice, as an embedded cultural practice over a number of years or if it’s another reason, there is a public interest in finding out what that reason is that and taking steps to learn lessons from these cases.”

In June, the Irish Prison Service launched its annual report.

At the launch, Irish Prison Service director general Michael Donnellan was asked about the deficiencies highlighted in the report into Prisoner A’s death — and about the inspector’s comments on how it was a recurring problem.

He said: “We’ve moved to a very sophisticated online computer-based system, our Prisoner Information System. The Inspector of Prisons rightly highlighted deficiencies when a death happens in custody and in relation to our record keeping and we have been taking a number of steps over the last number of months and indeed years to improve our record-keeping, especially from transitioning from paper-based records to electronic records.”

That answer doesn’t wash with Ms Malone, however.

“The quote from the inspector from the annual report in 2014 is not raising concerns about the way in which or the format in which things are being recorded,” she said. “What is being raised is the tendency to put as a little on paper as is necessary, to ‘keep it short and cover your arse’. That’s not going to be addressed by IT systems. That’s a cultural issue, or it’s a training issue, but it’s certainly the message that is being received.

You are being charged with the management and supervision of people. You are being required to check them every 15 minutes. And if it’s not happening, an IT system is not going to ensure it happens.

Last March, in the aftermath of the publication on the report into the death of Prisoner A, this paper asked the Irish Prison Service if disciplinary action followed the finding of misleading record-keeping.

While it confirmed that disciplinary proceedings followed, it said: “The Irish Prison Service does not comment on the outcome of such disciplinary cases.”

The IPRT is concerned that any disciplinary action taken to date has not been a sufficient deterrent to prevent the problem arising again.

“There’s no job where you can fail to fulfill a core and key function of your role and there are no consequences to that,” said Ms Malone.

“I think it would be very helpful to know what the consequences are in these cases. Because that is an important part of accountability. Ensuring accountability is about people understanding and knowing that if this happens there will be consequences, and we’re not going to tolerate it.

“But the fact that this keeps coming up again and again tells me that it is being tolerated.”

For the IPRT, the repeated issues that arise when a vulnerable person dies in an Irish prison highlights the need for greater oversight of the penal system.

“One weakness that this highlights is that, currently, the inspectors’ recommendations are only that, they are recommendations and if they are not acted on, there is no consequence for the Irish Prison Service at all, other than if it is made public or there is a particular spotlight drawn to it,” said Ms Malone.

“But there is no functional consequence if recommendations are not taken on board.

That is something that needs to be examined because when a death occurs in custody, there has to be effective mechanisms of investigation to uncover all the circumstances and that needs to go beyond just apportioning blame to a person or persons.

“It has to go towards improving the system overall so that if there is any positive legacy from the tragedy of a death in custody, it should be that concrete and effective changes are going to be swiftly introduced that will prevent some other mother from losing their child.”

Measures to address issues raised in report

The Irish Examiner submitted a number of queries arising from these reports to both the Irish Prison Service and the Department of Justice.

A number of questions were submitted, including a query as to whether staff found to have provided misleading records are disciplined, and, if so, what specific disciplinary action was taken.

A joint statement was issued in response:

The Minister for Justice and Equality pays careful attention to reports from the Inspector of Prisons (IOP) in relation to all deaths in custody and, where deficiencies have been addressed by the Inspector of Prisons, the minister has received proposals to remedy these deficiencies from the Director of the Irish Prison Service, who shares the concerns of the Minister in relation to those operational deficiencies illustrated by the IOP in some of these reports.

The Director-General has assured the Minister that he shares the view that these issues are of the utmost importance. He has underlined to prison management and staff the need for full compliance at local prison level in this regard.

To strengthen compliance, the Director-General has advised that measures to address the issues raised in the IOP reports are currently being progressed as a matter of urgency.

These include:

- The modification of prison landing lighting to ensure visibility of staff conducting checks on CCTV.

- The amendment of the IPS CCTV policy to provide prison management with the ability to review all night duty CCTV footage to satisfy themselves that full compliance with night guard duty is taking place on a consistent basis.

The introduction of:

- A new monitoring of prisoners policy;

- A new Healthcare Special Observations Policy;

- A Revised Close Supervision Cell Procedure;

- A Revised Safety Observation procedure;

- A new monitoring of prisoners during night guard duty protocol.

The director-general has advised the minister that implementation of the above policies/protocols will be supported by a communications strategy to ensure staff awareness and appreciation of the serious consequences for non-compliance.

The minister is regularly briefed by the director-general.

The Department of Justice’s response to follow-up questions about disciplinary action was not received by this article’s deadline.

Case Studies

Prisoner A (2012)

A 27-year-old father-of-one, Prisoner A died by suicide on 17th January 2012, less than a month after he was committed to Mountjoy.

He was committed to prison on the 20th December 2011. His release date was to be the 18th December 2014.

He had history of drug and alcohol abuse, and a history of seizures. He was reported ‘sick in cell’ on January 16 and was found dead the next day with a note.

Findings: “Appropriate records were not kept and therefore the deceased was not visited by a Nurse Officer/Medic as should have been the case,” the Inspector’s report found.

Correct records were not maintained by Officer C the Night Guard on duty on 16th/17th January. The Night Guard Report for D1 and D2 Landings for the night of the 16th/17th January 2012 states:- Patrolled the landings throughout the night finding all correct”.

Prisoner B

‘Prisoner B’ was a 24-year-old single man who died by suicide in Limerick Prison on 21st January 2012.

The deceased had a known alcohol and prescription drug problem. He was known to the prison psychiatric services and also to the community based psychiatric services.

Findings:“ Prison management have been unable to provide me with accurate records either in electronic form or otherwise to assist me in determining whether the deceased was or was not on Special Observation at the date of his death.”

The medical records were incomplete, inconsistent and demonstrate poor follow up on key aspects of healthcare.

"Therefore, on the balance of probabilities, I conclude that the deceased was not on the Special Observation List on the date of his death.” 

Prisoner K

Prisoner K was a 34-year-old married father when he died in the Mid-Western Regional Hospital, while in the custody of Limerick Prison, on 11th October 2013 following an incident on 7th October 2013.

The deceased had a history of depression. He had self harmed and had attempted suicide on several occasions. He also had a history of alcohol and drug misuse.

The deceased was known to the psychiatric services in the community and in prison. He had been an inpatient in a psychiatric hospital.

CCTV footage also indicated that he went unchecked for a period of 1 hour 24 minutes 19 seconds, commencing at 2.33.06pm.

Findings: “The deceased was not checked in accordance with Standard Operating Procedures. Prior to being found at 5.38.52pm, the deceased had not been checked for 1 hour 23 minutes and 2 seconds when he should have been checked every 15/20 minutes.

In fact, between midnight and 3.57.25pm, there was a failure to check the deceased during eleven other separate periods ranging from 24 minutes 34 seconds to 3 hours 8 minutes and 49 seconds when he should have been checked every 15/20 minutes.

Prisoner N

Prisoner N was a 50-year-old married father who died on 29th December 2013 in Wheatfield Prison. He came from the Dublin area and was survived by his wife and children.

The deceased suffered from serious medical conditions. The deceased was categorised as a Special Observation Prisoner – medical.

Findings: The Inspector reported that protocol dictates that he “must be provided with relevant documentation in accordance with an agreed checklist within certain time limits by a relevant prison”.

I am sorry to report that, in the instant case, the prison did not adhere to the agreed protocol. This meant that my investigation was prolonged and made more difficult as I had to request individual pieces of information, in some instances many times.

“In examining the times.. it is clear that .. the deceased was checked 12 times whereas he should have been checked at least 38 times as a special observations prisoner in accordance with the Standard Operating Procedures.

"The entries referring to Special Observation Prisoners in the journals...being official prison records, were certainly misleading in their content and but for the CCTV viewed by me would have been accepted by me as representing compliance with the relevant Standard Operating Procedures” 

Prisoner H

Prisoner H was a 37-year-old Polish father of two, who was in custody following his arrest on a serious charge which related to the death of his wife.

He died by suicide on August 26 2014, having been under special observation in Cloverhill Prison.

Findings: “While the checks of the deceased...were frequent they did not accord with Standard Operating Procedures which dictate that a prisoner, such as the deceased, should be checked every 15/20 minutes.

“The deceased was not checked for a period of 25 minutes and 37 seconds prior to his discovery... This did not accord with Standard Operating Procedures.

It appears that the deceased was last visited by a member of the medical team 3 hours 33 minutes and 16 seconds prior to being discovered.

“The official prison record, being the Close Supervision Cell Journal, detailing the times that the deceased was checked does not accord with the facts, namely, the times disclosed on the CCTV.

“Public officials must realise that it is a serious matter to create inaccurate public records”.

Prisoner M (2014)

Prisoner M was a 23-year-old homeless man with a history of drug problems who was survived by his mother and a brother when he died in Wheatfield Prison on Christmas eve 2014.

The inmate was visited the day before he died by his girlfriend, who gave him a package he put in his mouth before being brought to a close supervision cell and placed under special observation.

Findings: “However, on seven occasions the deceased was not checked every 15 minutes as provided for in relevant Standard Operating Procedures” The three most significant failures saw him go unchecked for periods of 64, 53, and 41 minutes at a time.

“The journal contains entries to the effect that the deceased was observed every 15 minutes from 11.30 hours on 23 December to 07.30 hours on 24 December.

“There is an entry to the effect that the deceased was given his dinner at 12.00 hours but another entry is to the effect that the deceased declined his dinner.

Certain entries in official documents (namely, the Night Guard Journal and Cell Journal for cell 12) are incorrect, misleading and do not accord with the facts in that they purport to show that the deceased was checked every 15 minutes in accordance with Standard Operating Procedures.” Toxicology tests proved positive for the presence of heroin and diazepam.

“All prison personnel must appreciate that official documents must reflect the truth of actions taken by officers.” 

Prisoner C

Prisoner C was a 23-year-old man from Dublin who was survived by his mother, his siblings and his extended family when he died on 10 March 2015 in the Mater Hospital while in the custody of Mountjoy Prison.

Findings: “Serious issues of significant concern are raised in this Report,” the inspector found.

“Throughout the night of 4/5 March 2015 the deceased was described variously as being agitated to being highly agitated. He expressed various concerns for his own safety and for his life”.

The deceased was checked by prison staff on 28 occasions during the night at regular and at times irregular intervals. As a ‘special obs’ prisoner he should have been checked every 15 minutes. On eight occasions the time intervals between such checks exceeded 15 minutes with intervals ranging from 19 minutes 3 seconds to 1 hour 21 minutes and 46 seconds.” Prisoner C was found unresponsive in his cell on the morning of March 5, following a suicide attempt. He was brought to hospital where he died on March 10.

The inspector warned that: “Proper, adequate and appropriate records must be maintained.” “When the status of a prisoner is documented as ‘special obs’ this must be taken seriously as it suggests an element of vulnerability.

“Prison personnel, of all grades, must be aware that the management of ‘special obs’ prisoners or those considered ‘vulnerable’ carries a high degree of responsibility.

Prisoner M (2015)

Prisoner M was a 30-year-old man who died on 28 July 2015 while in the custody of Portlaoise Prison.

He was survived by his Partner, two sons, his mother and siblings.

The prisoner was committed to prison on 16 September 2014 with a remission date of the 16 March 2016.

Findings: “From my examination of CCTV footage from 08.00 to 21.00 on 28 July 2015 there are several periods throughout the day when the deceased, who was locked in cell 6 was not checked in accordance with the Standard Operating Procedure relating to these cells.

Records show that the deceased was checked in the cell every 15 minutes from 21.00 on 26 July 2015 to 14.15 on 27 July 2015 when this was not the case. While the cell was checked on 29 occasions during that period there were several periods of up to or in excess of one hour between checks contrary to the Standard Operating Procedures.

 

Prisoner P

Prisoner P died on 5 September 2015 in Midland Regional Hospital, Portlaoise while in the custody of Midlands Prison A 65 year old man survived by his sister and extended family, Prisoner P had a complex medical history, and died on 5 September 2015 in Midland Regional Hospital, Portlaoise while in the custody of Midlands Prison He collapsed in his cell on the morning he died.

Portlaoise Prison

While the Breakfast Guard’s Report stated that the officer had “checked on all prisoners as required. Found all to be correct”, days later the same officer filled out a report in which he admitted that he took ill and left his post before actually carrying out the checks.

“I wrote out my report in the breakfast guard report book on good fate [sic] that I was going to check the prisoners during the break, but when I stood up from the chair to go and start my checks, I got very dizzy and had to sit back down,” the officer said.

Findings: The inspector found that “the note of the duties carried out by the Breakfast Guard set out in the Breakfast Guard’s Journal...is not correct.

The deceased was not checked every 15 minutes in accordance with Standard Operating Procedures during the night of 4/5 September 2015.” While the Inspector found that the inaccuracy in the records “did not contribute to the deceased’s death,” he called upon the governor to “comprehensively address” the incident.

Prisoner A (2016)

Prisoner A was 29-year-old man from the Dublin area who died by suicide in Mountjoy Prison on 13 February 2016, and was survived by his father, sisters, brothers and extended family.

Findings:“The deceased was not checked between 02:33:57 and 04:35:20 which is in breach of the Irish Prison Service Standard Operating Procedures.

“The Night Guard records created during the course of the night are wholly incomplete and are in breach of Standard Operating Procedures. The hand over of charge between officers at meal breaks or for any other reason were not recorded in the Night Guard Book.

“The Governor should take appropriate action to deal with the non-compliance by staff with Irish Prison Service Policy and Standard Operating Procedures.

The poor level of record keeping should be addressed by the Irish Prison Service. This may require some In-Service training or some other on the job training as poor record keeping has been raised as a concern in a number of previous Death In Custody Reports.

Prisoner J 

Prisoner J was a 21 year old man who died on 4 December 2016 in Mountjoy Prison, survived by his girlfriend and family.

Findings:“The deceased self-harmed on several occasions while in custody and attempted to take his own life on a number of these occasions.

The deceased was not checked in accordance with Standard Operating Procedures every 15 minutes.” He was found dead in his cell, having taken his own life.

“Prison personnel, of all grades, must be aware that the management of ‘special obs’ prisoners carries a high degree of responsibility and must ensure that the Standard Operating Procedures are complied with.”


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