Prison staff did not warn colleagues an inmate was on suicide watch before he was found hanged in a courthouse holding cell, a report has found.
Shane Rogers was on remand at Cloverhill Prison, Dublin, in December 2011 for killing Crossmaglen GAA star James Hughes when he died.
A report by Judge Michael Reilly, Inspector of Prisons, found Rogers had not been monitored for almost an hour after a court appearance.
The inspector said it is clear that prison staff charged with escorting and detaining Rogers at holding cells in the prison-linked courthouse had not been told about his vulnerable state of mind.
Rogers had admitted killing Mr Hughes while in custody and was assessed as a suicide risk.
Justice Minister Alan Shatter published the report of the inquiry into the jail death as part of a new regime put in place last April.
“I would like to express my sincere sympathy to the family of the late Mr Rogers and indeed to all of those affected by this tragic case, in particular the family of the late James Hughes,” the minister said.
“I hope this report, which regrettably has identified some system failures, will help to clarify matters for them.”
The report said there were a number of deficiencies including a failure of prison staff to communicate with each other, failure to adhere to stated work practices, an absence of governance to ensure compliance with standard procedures and inadequate record keeping.
“I have been assured by the director general that action has already been taken by prison management in relation to a number of issues,” Mr Shatter said.
“Enhanced arrangements have been introduced in relation to the notification of the vulnerable status of prisoners to escort staff.”
One change to the system in Cloverhill means all vulnerable prisoners are now returned to the prison immediately after a court hearing finishes.
Rogers, 32, of Deery Terrace, Inniskeen, Co Monaghan, was involved in a row with Mr Hughes before he killed him with one of his legally held firearms in the early hours of December 11, 2011.
He had twice punched Mr Hughes, All-Ireland club medal-winning captain of Crossmaglen Rangers, from Co Armagh, after seeing him with his ex-girlfriend Patricia Byrne in a Dundalk nightclub.
Mr Hughes was shot and died, while Ms Byrne and taxi driver Anthony Callan were injured when Mr Rogers opened fire after the cab pulled up outside her Dundalk house.
Martin Crilly, solicitor for the dead prisoner's parents Margaret and Sean, said they were relieved to learn how their son had died.
“The Rogers family are relieved to receive the report of Judge Michael Reilly, the Inspector of Prisons,” he said.
“They did not know until receiving Judge Reilly’s report the exact circumstances of Shane’s death.”
The family said they welcomed the Justice Minister’s decision to publish inquiries into prison deaths.
“They are very upset to learn about the breakdown that arose in relation to Shane’s death, particularly that the Prison Service Escort Agency attached to Cloverhill Prison were not told that Shane Rogers was vulnerable and suicidal,” they said.
“They are also very upset that Shane was not checked by the prison service for approximately 55 minutes between 12.03-12.58pm during which time he died, despite a specific requirement that prisoners are checked every 15 minutes,” they said.
“The family accept Judge Reilly’s findings. They hope that the recommendation now made by Judge Reilly will avoid a similar tragedy happening and that some good may come out of Shane’s death.”
Man found dead in cell was Dundalk shooting accused