Cork Prison officers didn't hear emergency alarm after volume turned down
Prison officers in Cork Prison failed to hear an emergency alarm and call button activated by a prisoner who died a short time later because the volume had been reduced to the minimum level possible. Picture: Dan Linehan
Prison officers in Cork Prison failed to hear an emergency alarm and call button activated by a prisoner who died a short time later because the volume had been reduced to the minimum level possible.
A report by the prison watchdog revealed the unnamed prisoner was found unresponsive in his cell on October 2, 2021 over 30 minutes after he had sought assistance from prison staff.
An inquiry of the incident also resulted in the Office of the Inspector of Prisons (OIP) issuing an immediate action notification because deficiencies in the call button and emergency call systems created a “very high risk.”
The OIP report revealed the 54-year-old prisoner had sounded the call button and emergency alarm within six seconds of each other at 9.04am.
However, prison officers were only alerted to his condition when they went to unlock his cell door for breakfast at 9.36am.
Despite efforts to resuscitate him, he was pronounced dead at 10.26am.
The report said prison staff had failed to hear the call button and emergency alarm because their volume had been reduced to the minimum level possible.
The watchdog said only a faint buzz could be heard when standing close to the handset for the call button alarm, while nothing could be heard from the emergency alarm device.
The OIP also found the cell alarm light was obstructed by notices on a glass panel and railings which prevented prison officers based in an office from seeing it.
A prison governor stated he was unaware the volume could be manually adjusted to the minimum level.
Following the prisoner’s death, the governor issued an order that stipulated that volume levels on such devices should not be muted or turned down below audible levels at any time.
The OIP said there was no evidence that prison officers had complied with a prison rule that requires them to examine any equipment for which they have responsibility on taking up duty.
During an unannounced inspection of Cork Prison last year, the OIP verified that the volume issue was no longer a problem but said it remained the case that only certain cell alarm lights could be seen from the office where staff were based.
The OIP said it also had to raise an immediate action notification during the inspection as it became aware that a call button alert cannot be cancelled without answering it.
They also found that no other emergency call can be answered until the first one in the queue is answered.
“The dangers of this situation are obvious. It could easily be the case that a genuine emergency call goes unremarked and unanswered for a critical period of time, leading to a variety of avoidable harms, up to and including the death of a person living in the prison,” the OIP stated.
However, the OIP welcomed the prompt response by the Irish Prison Service to address the safety issues raised in the notification.
It noted new high visibility call light boards had been installed in offices and phone systems had been recalibrated to resolve the issue of one unanswered call blocking all others.
The deceased had been in Cork Prison since being sentenced at Waterford Circuit Criminal Court on September 15, 2020.
The report also recorded that the prisoner’s family had raised concerns about the level of support provided by the State for people facing challenges with their mental health.
It noted the prisoner was described by his family as vulnerable and suffering from bipolar disorder and someone who became unstable if he did not take his medication.
The prisoner’s sister said she was unhappy that her brother used to be locked in his cell for up to 23 hours per day as it was not good for his mental health.
The report observed the woman felt that “all arms of the State had left her brother down” as they had spent years unsuccessfully seeking mental health and housing support for him.
His sister said she strongly believed that prison is not the answer for people suffering from a mental illness.
The report said the prisoner had engaged with the prison’s addiction service on 27 occasions between February 2021 and his death.
An addiction counsellor who saw the prisoner four days before his death said he had been in good form with “no red flags.” Nursing staff said there was nothing unusual about him on the day prior to his death and he was recorded as taking all his prescribed medication.
The OIP made a series of recommendations based on its findings to the IPS, including that volume controls on all emergency devices across prisons in Ireland be fixed at an audible volume that cannot be lowered or deactivated.
The recommendations also addressed a finding that information provided by one prison officer about checks carried out on prisoners was contracted by CCTV.
The report also revealed that no cold debrief about the prisoner’s death was held as required by IPS standard operating procedures, while only one staff member involved in the incident attended a hot debrief.
