The story painted by Gráinne McMorrow SC is as depressing as it is exhaustive.
Much has improved in the State’s prisons and forensic mental health services since 2006, which the barrister acknowledges, but it is yet to be seen whether enough has changed to prevent such a scandal happening again.
Ms McMorrow sets out a chain of events leading up to the savage killing of Douch at the hands of Stephen Egan, a diagnosed psychotic with a history of extreme violence, in a packed cell in the basement of Mountjoy Prison on August 1, 2006.
For Douch, from Coolock, north Dublin, it started in early 1997 when, aged 12, a court recommended he be placed in a health board special care unit. But there were no vacancies. Instead he continued on a life of crime, eventually leading to a three-year sentence for a serious assault.
That led him to Mountjoy Prison. After asking to be placed on protection, he was put into a “holding cell” in B Base on July 31, 2006, along with six others, including Egan.
Egan, also from Coolock, started his experience with the courts at the age of 15. He spent his young life in a number of institutions. He moved regularly as he earned a reputation for aggressive and violent behaviour towards prisoners and staff.
In November 2005 he nearly killed a female prison officer in an escort. Despite this, he failed to receive psychiatric treatment.
When he was seen by a doctor he was put on anti-psychotic medication. A psychiatrist said he was in need of “ongoing psychiatric review”.
Over the next five months, he received no such care, despite refusing to take his medication.
In July 2006 he was transferred to the Central Mental Hospital, where he was diagnosed as “acutely psychotic”. But within nine days he was deemed “fit to return to prison”. He was taken to Cloverhill Prison.
Management there repeatedly asked Mountjoy to take him back, a request they initially refused before accepting in return for Cloverhill taking five inmates to ease their overcrowding.
No medical or psychiatric staff were consulted and he was transferred, somehow ending up in B Base holding cell. Fuelled by paranoia and off his medication, Egan, weighing 16.5 stone, launched a ferocious, and fatal, assault on Douch, who had turned 21 the previous week.
In the raft of damning findings, Ms McMorrow said:
* Egan should not have been discharged from the CMH back to prison, nine days after his admission.
* Management at Cloverhill Prison showed “a reckless disregard” for Egan’s health and safety by sending him to Mountjoy.
* They showed the same “reckless disregard” for staff and prisoners there.
* The governor on duty in Mountjoy, trying to deal with “severe overcrowding”, agreed to the transfer as Cloverhill were taking five inmates in return.
* This governor did not know two other governors, including head governor John Lonergan had refused to take Egan.
* Overcrowding at Mountjoy “completely undermined” the ability of the prison to respond to Douch’s request for protection and was “critical” in the circumstances leading to his death.
* Conditions in the holding cell were “appalling and unacceptable” and provided an “unacceptable safety and security risk for prisoners and staff”.
* The regime at Mountjoy was “inept, dysfunctional, and showed a reckless disregard for the safety of prisoners and staff”.
Ms McMorrow said “Governor Lonergan of Mountjoy Prison and Governor Somers of Cloverhill Prison [both retired] must bear considerable responsibility for what tragically transpired”.
Mr Lonergan yesterday accepted that as governor he had to shoulder some responsibility, but said the “single biggest factor” was the chronic overcrowding.