They include dozens of measures to ensure better mental health treatment for those in the prison system, including a number of new units on sites closer to and within prison grounds and significant mental health training for prison officers.
The report makes recommendations on procedures to ensure continuity of mental health treatment when prisoners are transferred between facilities.
A significant number of recommendations focus on the overcrowding which put Mr Douch in a “protection” holding cell with six others on the night he died and which remains a problem today. They include measures on how to accommodate violent prisoners as well as those who need protection.
Justice Minister Alan Shatter said it was clear Mr Douch’s death was “avoidable and should not have happened”. He apologised to his family on behalf of the State and the prison service.
The Irish Prison Service said its system in 2014 “is very different from the system which operated at the time of this tragedy in 2006”.
“Given the lapse of time, many of the deficiencies highlighted in the report have already been addressed,” it said.
“Significant improvements have been achieved in a number of areas including: reduction in overcrowding, prisoner accommodation, services to prisoners, prisoners requiring protection, committal assessment procedures and healthcare assessment and provision.”
Mr Douch’s mother Margaret Rafter, who met with Mr Shatter yesterday, said the killing of her son was a preventable tragedy and said he died in appalling circumstances of squalor and unsafe Third World conditions of overcrowding and poor decision-making.