Death in Custody Investigation Report published for a death occurring on 15 Jan 2022

30th May 2023

On 31 May 2023, an Office of the Inspector of Prisons Death in Custody Investigation Report was published by the Department of Justice and Equality. The report is related to a death that occurred on 15 January 2022. The Inspector of Prisons investigates all deaths that occur in prison custody and also deaths that occur within one month of release from prison. The report relates to a death that occurred while the individual was in custody while on remand.

The Irish Prison Service has responded to the Inspector’s recommendations in Action Plans published alongside the reports. Since 2020, action plans that make recommendations for change have been published alongside any death in custody investigation reports (as recommended by IPRT in previous editions of PIPS). In these action plans, the IPS outlines progress towards implementation of the OIP’s recommendation(s), including assigning responsibility to specific actors and a timeline for completion. Once-off action plans with no follow up information on implementation are not wholly sufficient as it is not always clear whether the recommendation has been actioned by the timeline given. PIPS 2022 echos previous recommendations made, that the Irish Prison Service should publish progress reports towards the implementation of recommendations made by the Inspector. (See PIPS 2022, Action 25 p.69) 

IPRT is clear that investigations into deaths occurring in prison custody must be prompt to ensure that any systemic issues are identified and addressed in order to prevent potential future deaths. IPRT remains concerned about delays in publishing these reports, which play an important preventive and improvement role. (See PIPS 2022, Standard 25, p.68)

In the case of Mr C, inadequate staffing levels was highlighted, resulting in cancelled appointments. IPRT welcome the seven recommendations outlined by the Inspector in the case of Mr C, who was pronounced dead in his cell on the 15 January 2022 in Cork prison.

Recommendations of the report by the Inspector of Prisons included:

1. It is recommended that the Irish Prison Service put in place the necessary staffing arrangements (including, if necessary, revision of Regime Management Plans) to ensure that prisoners’ appointments to attend healthcare clinics are not cancelled because prison staff are unavailable to escort them. This is particularly critical in relation to referrals to psychiatric inreach clinics; the necessary staffing resources to escort prisoners to appointments of this nature should be “ring fenced” in the Regime Management Plans of all prisons in the State.  
2. If, exceptionally, a person in custody cannot be escorted to an ordinary somatic healthcare appointment due to acute staff shortages or other operational reason(s), a record of any appointments that are cancelled for this reason should be maintained by healthcare personnel and the Governor in charge of the prison notified of these on a weekly basis by the Chief Nurse Officer. Any prisoner whose health care appointment is cancelled for this reason, should be facilitated to attend a replacement appointment as a matter of urgency.  
3. Prison Governors should be reminded of their obligation to comply with the Irish Prison Service Standard Operating Procedure (SOP) titled ‘Critical Incident Reporting and Debriefing Procedures’ which came into effect on 1 July 2020.  
4. It is recommended that the Irish Prison Service ensure compliance with Prison Rule 13(1) and (4) of the Prison Rules 2007 – 2020 which requires the Irish Prison Service to provide each prisoner with an information booklet outlining their entitlements, obligations and privileges; the booklet should, “as far as practicable be provided to a foreign national in a language understood by him or her”.  
5. The Irish Prison Service must ensure that all telephone numbers are accurately recorded on the phone cards of prisoner and that, once activated on the phone card, they are working. It should also ensure that the operation of the system is explained to the person in custody, particularly if it is their first time in custody.  
6. The Irish Prison Service should, in accordance with Rule 46(4)(a) ensure that a remand prisoner is permitted to make not less than five phone calls per week and if any of these calls fail, the reason should be recorded.  
7. It is recommended that an inventory of all clothing and other personal items in the possession of a person on committal should be recorded in accordance with Rule 8(1) of the Prison Rules 2007-2020, this inventory should include clothing and its label. In addition, a similar inventory should be made of all items returned to the family/next-of-kin following a death in custody and separately a list should be compiled by prison staff of any item(s) taken into the possession of An Garda Síochána.