Jailers failed to check suicide victim

Limerick Prison failed to follow its own procedures to watch over a man who took his own life while on suicide watch.

This was the finding of the Inspector of Prisons, Judge Michael Reilly, who investigated the death of the prisoner last October.

The unidentified man was married with children. He was sent to prison in January 2013 and was due to be released this month.

The judge’s report, which was laid before the Oireachtas, said the line management structures in the prison at the time either did not exist or were deficient when it came to monitoring the man.

He said he should have been checked regularly but was not.

On October 7, 2013, the prisoner hanged himself with a shoelace tied to a bunk bed while he was in a special observation cell. He was found by another prisoner who tried to hold him up while efforts were made to cut him down.

The door of the cell had been opened by a prison officer just seconds earlier, but the man was not checked. The prisoner was taken to hospital and was on life support for four days.

The inspector said the man was not checked in line with the standard operating procedures for the prison.

The judge reviewed and documented all CCTV

evidence from the C3 landing where the man was under special observation.

“Prior to being found at 5.38pm the deceased had not been checked for one hour and 23 minutes and two seconds when he should have been checked every 15/20 minutes.

“In fact, between midnight and 3.57pm there was a failure to check the deceased during 11 other periods ranging from 24 minutes 34 seconds to three hours eight minutes and 49 seconds.

“Not alone were the 15/20 minutes checks not carried out, but hourly checks were not carried out on the deceased on five separate occasions,” he said.

The prisoner had a history of harming himself and had attempted suicide on a number of occasions.

The report revealed that the dead man had tried to take his own life in a very similar fashion two months earlier and had been reviewed by a psychiatrist and placed on the special observation list. He was taken off the list a week later but was put back on it in mid-September when he threatened to harm himself.

At that stage he was not sleeping properly, he had a poor appetite and his medical records said he was “drained of energy”.

The inspector said the dead man’s family had raised concerns about what he had used to hang himself, whether he was on the correct medication and how he was found.

The judge recommended that the Irish Prison Service develop management structures to make sure standard operating procedures within prisons are adhered to.