An independent review of all medical care in Cork Prison has been recommended following the death of a man in custody.
A jury of four men and two women made the recommendation at the inquest into the death of Andrew Gearns, 29, a loving father, “a joker”, and a talented soccer player who made a fatal attempt on his life in Cork Prison in September 2020 and later died in hospital.
Mr Gearns was suffering distressing delusions about being stabbed and had six risk factors for suicide but was seen by prison medical staff for less than five minutes on the day of his fatal attempt on his own life.
The former engineer from Model Farm Rd in Cork was heard calling for his mother and father in the hours before his death.
The jury called for the four recommendations made by the Office of the Inspector of Prisons (OIP) report, published just 48 hours before the inquest, to be adopted by the prison service.
They particularly highlighted the need for a clear handover to be given by gardaí to prison staff on a person’s committal to prison. This had been called for in an earlier inquest but had still not been implemented.
Any and all history of self-harm should be entered on the prison information management system — the IT system that all prison staff can access, the jury said.
A glitch in the prison IT system, which automatically entered information from a previous prison visit into Mr Gearns' medical file, must also be urgently addressed, they said.
Another matter to be addressed urgently by the Department of Justice, the Irish Prison Service (IPS), and the OIP was the delay in compiling the investigation report into a death in custody.
The jury also recommended that the full 72 hours of CCTV footage around a person’s death in custody must be provided to the subsequent investigation and should not be reduced to 48 hours, as it initially was in this case.
Following just over one hour of deliberating, the jury returned a unanimous verdict of suicide in Mr Gearns’ case.
Mr Gearns’ brother Evan Gearns said that the family believes that Andrew would still be alive today had his medical history been more thoroughly checked; if his GP had been called by prison personnel; and if he had been put in a special observatory cell due to a reported previous suicide attempt.
Evan also called on the Department of Justice to give coroners the power to enforce recommendations made in their courts “sooner rather than later”.
“If we can save one life from Andrew’s death we’ll be grateful,” he said, speaking outside Cork Coroner’s Court following the three-day inquest.
He described his brother as a prankster, a joker, and his mother’s brown-eyed boy. He was a talented soccer player and a loving father, Evan said.
Mr Gearns had developed a drug addiction after being prescribed benzodiazepines to cope with pain following a car crash in 2016. He entered Cork Prison “at a low ebb” on September 22, 2020, and was found unresponsive in his cell on September 28, 2020, after a fatal attempt on his own life.
Mr Gearns had been suffering distressing delusions for two days while in Cork Prison in September 2020 and had previously reported a suicide attempt to prison personnel in 2018.
He was not placed on special observation, which would have required him to be checked every 15 minutes. But he was checked on 13 times between 12.30pm and the time he was found unresponsive at 4.50pm on September 28, 2020.
Some of those checks in the hours before his death amounted to one- and two-second glances through the window in his cell door but staff tending him were described in court as being experienced, professional, and caring.
Coroner Philip Comyn said that the jury’s recommendations were “fair and reasonable”.
He added two issues of “general concern” to be addressed.
Although a previous inquest in 2019 had called for a person escort record, which would ensure that information on the prisoner is passed between gardaí and prison staff, it had still not been adopted.
Another concern was that it was taking too long for the OIP report into a death in custody to be finalised.
The inquest heard that OIP recommendations to increase safety in prisons are being repeated following subsequent deaths in similar situations which occur before the requested changes are made.
Helen Casey, deputy chief inspector with the OIP, agreed with senior counsel for the family, Elizabeth O’Connell, that lack of action on recommendations could be depressing.
The OIP investigates deaths in custody. The OIP’s report into the death of Mr Gearns was only published on January 30. His inquest began on February 1.
Ms Casey said the OIP has been operating under significant resource difficulties, with very few staff and a high turnover of members in recent years. But she said that new resources have been promised and a recruitment panel is now in place with people expected to be in positions by the summer.
“Regrettably, the drafting of reports is taking too long. It should be done on time, this is not the only report where there are delays,” she said.
In the recently published OIP report into Mr Gearns death, four recommendations were made: the IPS should introduce a person escort record to be completed by IPS staff or gardaí when a prisoner enters or exits prison, to include all known self-harm risks and vulnerability; potential ligature points and items of potential self-harm should be identified and form ‘daily inspections’ for those considered at risk; anti-ligature prison furniture should be evaluated; and information about a prisoner’s previous history of self-harm should be recorded in the risks and alerts system [a prison IT alert system], on the general IT system, and prison staff should be informed.