A “vulnerable” man suffering with a psychiatric medical condition, died in his cell at Limerick Prison after a “systems failure, in relation to his incarceration”, his inquest today heard.
Sean Hayes Barrett died six days before his 32nd birthday, while he was being held on remand at the jail, between 16 April and 5 May 2017.
His family said they had still not been told why he had been arrested.
Prior to his incarceration, Mr Hayes Barrett had spent five weeks in a psychiatric ward at University Hospital Limerick.
He was on medication to treat signs of suicidal ideation, but it was accepted that while he was being held in prison he was not given adequate doses of his medication.
He had no record of being arrested prior to his incarceration and he had no previous convictions.
He was found dead in his cell which he did not share with anyone on 5 May.
A handwritten note was found in his cell.
A post mortem revealed he died by asphyxia consistent with a ligature around his neck.
A number of prison officers, who were on duty at the jail on the night, gave evidence they had no prior knowledge of Mr Hayes Barrett’s psychiatric medical history.
They said they were “not aware” he was on a list of “special observations” prisoners, who as part of the prison’s own protocols, required they be checked every fifteen minutes.
The inquest heard that Mr Hayes Barrett should have been checked 36 times, but he was checked on only nine occasions.
He had complained to a loved one during a recorded telephone call made from the prison, that his mental health was suffering because he was being kept in a cell on his own.
“It’s too hard, I’m not able for the isolation - the isolation is too hard on me,” he said.
Investigations were carried out by Gardaí, the Inspector of Prisons, and by Limerick Prison.
Governor of Limerick Prison, Mark Kennedy said CCTV footage from the jail, which was requested by the Inspector of Prisons had “disappeared”, most likely due to human error, when it was being transferred “by our IT department” to the Inspector’s office.
He agreed prison officers were not aware of Mr Hayes Barrett was a special observation prisoner.
He said the prison’s “manual system” at the time - whereby a list of special observation prisoners would be printed out and left for staff on a sheet of paper - “wasn’t robust”.
“We weren't 100% that the officers on the night got the up to date special obs list,” Mr Kennedy said.
Sean’s death was a “landmark case” which proved to be a “watershed” for the prison service that led to a “root and branch review” of how prisons deal with vulnerable prisoners, it was heard.
New protocols have been implemented to try to prevent such a tragedy occurring again. He said: “The whole system has changed.”
An internal prison probe discovered the “practicalities of what we were doing as a service didn’t stack up”.
Prison protocols at the time meant it was “physically impossible” for staff to make all their checks and deal with any other emergency situations that could arise within the prison population, he said.
Staff were “diverted” to another serious injury on the night, it was heard.
“We didn't abide by our own protocols. Our own protocols were that he needed to be checked every fifteen minutes and that didn't happen,” Mr Kennedy said.
“It is fair to say this case was a landmark case, and, as a result of Sean’s death the whole system has changed throughout the prison service.”
Coroner, John McNamara, recorded an open verdict.
In deciding a verdict Mr McNamara said that “under Article Two of the European Convention on Human Rights, the state has a positive duty to prevent deaths where possible, and it appears to me there were system failures in respect of Sean Hayes’s incarceration”.
This is not disputed by the prison service or the governor.
“Sean Hayes was classified as ‘special observations’ on his committal to prison. It’s accepted this would require checks on him every 15 minutes. It’s also accepted this was not done.”
“It appears nine checks were carried out during the night in question but that, in fact, there should have been 36 checks.
“I accept evidence from the governor and prison officers that there are extreme demands on resources and there was another serious incident on this particular night in another part of the prison which diverted resources.”
“However the prison officers (on duty that night) weren’t aware of the special observations list or that Sean was on it.”
“I’m told that Sean Hayes’s death has been a watershed for the prison service and that significant changes have been implemented. I’m also told the Inspector of Prison’s recommendations have been largely implemented.”
Mr McNamara said the nature of Sean’s death “on the face of it would imply that it was a suicide” but he added, “having considered the matter and taken into account the system failures, I’m not happy to record a verdict of suicide”.
Mr Hayes Barrett's father Sean Barrett said he was “happy the truth is out today”.
“I love Sean and I miss him, and I will for the rest of my life, everyday.”
“Sean was very quiet, never in arguments, he was playing guitar and he was kickboxing and he was into reading and he loved animals.”
He was good. He’s gone now. What can I say. I love him and I miss him.
The family’s solicitor, Jerry Twomey reading a statement on behalf of the Hayes Barrett family afterwards said: “Sean had never been in any trouble whatsoever in his life. To this day he’s never been convicted of a single criminal offence.”
“Despite this, sean found himself incarcerated in Limerick Prison where after being deprived of his correct and prescribed medication, alone and vulnerable, he took his own life.”
“Today the Coroner recorded an open verdict. The Coroner recognised the many shortcomings of the prison service while sean was in their care.”
“There was also evidence that this was a landmark event in the prison service and that root and branch changes have been applied.”
“We are satisfied with the open verdict in Sean’s death and we are happy to hear that many others are safer as a result in the changes made, since, and because of Sean’s loss. We will miss and love Sean forever.”