Prisoner died day before his scheduled transfer to psychiatric unit, report says

A psychiatrist told the investigation team that 'accessing treatment in a community-based psychiatric facility is extremely challenging'

He was medically assessed by Cloverhill Prison’s healthcare staff and the Prison In-reach and Court Liaison Service team, whose task is to identify people suffering mental health issues when remanded to prison. File photo: Leah Farrell/© RollingNews.ie

The death of a prisoner in Cloverhill Prison occurred a day before he was due to be transferred to a psychiatric unit, according to the Office of the Inspector of Prisons.

A report into the death of the inmate has been submitted by the office to justice minister Jim O’Callaghan. The prisoner, identified only as Mr O, died on August 10, 2022, at the age of 52, while on remand for minor offences.

The report said the man’s cause of death is “a matter for the coroner”. He was arrested in Dublin Airport six days earlier, “due to his behaviour and for refusing to comply with the direction” of gardaí.

The man had arrived in Ireland the previous month from Spain to visit a friend. However, his friend asked him to leave their home “due to his erratic behaviour” prior to his arrest for a public order offence.

He had been granted a nil cash bond and would have been required to sign a bail bond confirming that he would not commit an offence and be of good behaviour following release. However, the report into his death outlined: “The investigation team were informed by Governor A that he considered that Mr O was not in a fit state of mind to take up his bail bond.” 

The report said that Mr O’s behaviour on committal was “erratic” and he was accommodated in a “close supervision cell”. 

He was medically assessed by the prison’s healthcare staff and the Prison In-reach and Court Liaison Service team, whose task is to identify people suffering mental health issues when remanded to prison.

The report continued: “Mr O was scheduled to be released from Cloverhill Prison under the Mental Health Act 2001 to St Vincent’s Psychiatric Unit on 11 August 2022. However, Mr O was discovered unresponsive in his cell on August 10, 2022.” 

The report also outlined that on August 8, a psychiatrist, A, recorded on the Prisoner Healthcare Management System that a call had been received from gardaí saying that the judge “would be striking out charges” against Mr O “if treatment could be arranged, given his current mental state”. 

The investigation team were told that Mr O had spent time in a psychiatric hospital outside the jurisdiction, "and it was believed he had not taken his prescribed medication over the previous 10 months”.

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A second psychiatrist, B, told the investigation team that “accessing treatment in a community-based psychiatric facility is extremely challenging”.

Referencing the 2006 Vision for Change document on mental health services, the psychiatrist “pointed out that, 17 years later, mentally ill persons in prison custody still cannot easily gain access to psychiatric community-based facilities”, said the report, adding that “this lack of access results in prisoner-patients not receiving the mental health treatment they require.” 

The report continued: “This is consistent with the Inspectorate’s findings during its recent thematic evaluation of the provision of psychiatric care in the Irish prison system.” 

The report also said: “Mr O died in prison before his legitimate mental health treatment needs could be met. This only serves to underscore the urgent need to forge new system-wide clinical care pathways, including rapid transfer to local civil psychiatric hospitals, for prisoner-patients such as Mr O.” 

The report is calling for “urgent consideration” to be given to “the systemic changes that are required to facilitate the swift transfer of persons suspected or convicted” of minor offences, “who have mental disorders, to local psychiatric hospitals”.

It added: “As this is likely to require the development and opening of appropriately secure, intensive care facilities/designated beds in civil psychiatric hospitals, this calls for a multi-agency approach.” 

Falsification of records

Meanwhile, the report also said that it “is imperative that the falsification of records is treated with the utmost seriousness”, after the investigation team found that three entries confirming special observation checks were conducted at Mr O’s cell were carried out after the time of Mr O’s death.

The report outlined the three checks were recorded as being conducted at 7am, 7.15am, and 7.30am on the morning of Mr O’s death – after he was found unresponsive at 6.50am.

“The investigation team noted that an (unsuccessful) effort had been made to erase the three entries,” stated the report, adding that it “clearly suggests” that the entries “were being pre-filled by staff, entirely negating the value of this recording safeguard”.