A lot of time has passed since Gary Douche was beaten to death by Stephen Egan, a seriously ill man deprived of his medication, in a packed cell in Mountjoy Prison in Aug 2006.
Things have changed in the Prison Service, but the difficult tasks of protecting vulnerable prisoners and treating inmates with serious mental health problems are still very much live issues.
The Commission of Inquiry, set up in 2007 to investigate the death, has not been able to publish its final report.
The family of Gary Douche, while kept in the loop by chairwoman Gráinne McMorrow SC, still do not know what happened that night.
The wider community, including policymakers, do not have the knowledge to prevent such appalling violence from happening again.
Mr Douche had just turned 21 when he suffered an awful death on Aug 1, 2006, in an overcrowded basement of Mountjoy.
Cell 2 in B Base was 19sq ft in size and housed seven inmates on the night.
One of them was Stephen Egan, aged 23 at the time, and weighing 16.5 stone. Both men were from the Darndale area of north Dublin.
Driven by unfounded paranoia that Mr Douche had raped his sister and abused his mother, he kicked and stamped Mr Douche to death.
He told gardaí: “I was kicking him into his head. A kick into the chest, like a football kick, like Ryan Giggs.”
He said he dropped onto his chest in the frenzy, which lasted 10 minutes. He said he didn’t intend to kill him.
After the onslaught, Egan said he washed himself and defecated into a plastic bag.
“I put it on his face as a going-away present for his sister and my own sister. I rubbed it onto his face, but not into his mouth. I didn’t mean to put it in his ears.”
He said the cell mates covered Mr Douche with mattresses while he put on his walkman and went to sleep.
Egan was subsequently charged with murder. In April 2009, he was found not guilty of murder, but guilty of manslaughter by reason of diminished responsibility.
The Central Criminal Court heard he had a schizophrenic-type disorder and had not been provided with his anti-psychotic medication for up to three days at the time.
The court heard he had been transferred from Mountjoy to the Central Mental Hospital at the beginning of July 2006. He was treated for 10 days in the secure forensic hospital for hallucinations and persecutory beliefs.
Consultant psychiatrist Tom Fahy told the court that Egan suffered from schizo-affective disorder and paranoid beliefs. He said Egan was discharged from the hospital on July 14 and transferred to Cloverhill Prison, where he got anti-psychotic medication.
He was transferred back to Mountjoy. Initially, he was placed in a holding cell with two prisoners, but then with six. He had gone two to three days without his medication.
“He had gone from round-the-clock seclusion in the Central Mental Hospital to sharing a cell with six other prisoners,” said Prof Fahy.
He described as “surprising” the decision to discharge him from hospital.
In addition to the questions surrounding the handling of Egan, there are also issues with the management of Mr Douche.
The night before his death, Mr Douche had pleaded with prison bosses to be put in protective custody, as he feared for his safety.
Then justice minister Michael McDowell said “very serious mistakes” had been made and set up the commission, tp be led by MsMcMorrow, to get to the bottom of the matter.
However, that inquiry has been dogged by delays and obstacles.
While the trial and a subsequent appeal understandably held up the inquiry, the probe has also struggled to get the necessary information and evidence from some of the relevant parties.
Ms McMorrow told the Irish Examiner that information sought by the inquiry as far back as 2007 and 2008 had only last year been made available.
She said she completed a draft report — totalling 500 pages — in March 2012, copies of which were sent to all the relevant people.
“This generated a lot of new evidence and different information, which required additional hearings.”
Under the Commission of Inquiry legislation, which governs her investigation, Ms McMorrow is legally obliged to consult relevant people when changes are made to her report. This has repeatedly delayed the report.
Despite all the hold-ups, the chairwoman said the commission was “determined” to deliver the final report to the justice minister by the end of the year.
Ms McMorrow is the sole member of the commission of investigation. While the budget supplied by the Department of Justice has continued to cover the costs of the investigation, including hearings and part-time legal counsel and expert professionals, she herself has not been paid since Jan 2007.
“I haven’t been paid for three and a half years,” said Ms McMorrow, who herself suffered double tragedies this year, with the death of her husband and her mother.
She said she received an interim, partial payment last January and that discussions were ongoing regarding the rest of the money owed, including her salary since January.
She said she had always been prepared to do all the additional work after the report was published, which could last for up to six months, for free. She pointed out that her private practice was “negligible”, but that she had tried to keep it going.
The Irish Penal Reform Trust said the repeated delays were a matter of “grave concern”.
Director Liam Herrick said: “We’ve always had full confidence in Gráinne McMorrow and her attempt to carry out a full investigation.
“We are aware there are concerns regarding the powers of investigation the commission has to ensureevidence is made available. We are also aware of concerns regarding the resourcing of the investigation.”
He said they would have to wait until the full report is published before they knew the reasons behind all of the delays.
Mr Herrick said the State had a legal obligation — established by successive rulings of the European Court of Human Rights — to set up investigations into deaths in custody that are “independent, comprehensive and conducted within a reasonable time period”.
He said: “The State has an obligation to ensure an independent investigation is carried out. How they do that is up to them, but the system must be effective.
“The fact that there has been such a delay and difficulties in resourcing the investigation — the responsibility lies solely with the Government.”
Mr Herrick said major issues were being examined by the commission. “There are serious issues about assessment or risk, the protection of vulnerable prisoners, the appropriate treatment of mentally ill prisoners,” he said.
In a matter of months, almost seven years on, we should have a comprehensive report on these matters.