23rd July 2024
The publication of the Office of the Inspector of Prisons’ (OIP) investigation report into the death of Mr K 2024 in Cork Prison is timely and provides clear pragmatic recommendations for the Irish Prison Service (IPS). This is particularly relevant at a time when the IPS has issued an urgent alert after reports of a recent fatal overdose of nitazene (a strong synthetic opioid) in the prison estate in July 2024.
The investigation report into Mr K’s death in Cork Prison on 14 March 2024 details the events leading up to his death and the investigation by the OIP afterwards. While the report deals solely with the facts of the case, IPRT notes that the report also serves to highlight several key issues of concern currently impacting people in prison including overcrowding, the overrepresentation of people with addiction issues and/or severe mental health needs in prison and the presence of illicit substances in the prison estate.
Mr K, a 27-year-old man was remanded into custody and was committed to Cork Prison on 8 March 2024. On admission he informed the prison healthcare staff that he was a regular drug user and was subsequently placed on a waiting list for addiction counselling.
However, after being found unresponsive and sent to hospital, on his return to prison just over three hours later, he was returned to his original cell before being moved to the Vulnerable Persons Unit (VPU). It was determined that he had experienced a seizure due to drug withdrawal. This unit is for people with ‘enhanced medical needs’ both physical and psychiatric as outlined in the OIP’s Thematic Inspection: An Evaluation of the Provision of Psychiatric Care in the Irish Prison System. The thematic inspection, separate to this death in custody report, took place in February to March 2023 but was published in February 2024. As part of the thematic inspection, the OIP visited Cork Prison observing that:
Although the VPU is for prisoners with enhanced medical needs (somatic and psychiatric), at the time of the visit, all had mental illnesses which required additional supervision and care, with all prisoners on the unit being deemed too vulnerable to cope in the general population.
Notably at the time that the Inspectorate’s Thematic Report was conducted in early 2023, the OIP observed that the seven cells in the VPU were ‘full’ with ‘no doubling or tripling of cells’. By March 2024, however, this situation had changed with a doubling up of cells. In this instance, two people both assessed and deemed as vulnerable – Mr K because of substance misuse and addiction issues leading to an emergency visit to hospital and Prisoner 1 due to self-harming – were placed in a cell together. While the Death in Custody report does not discuss why two people were sharing a cell in the VPU, official IPS statistics for 13 March 2024 indicate the severe level of overcrowding in Cork Prison with 30 more people in the prison that day than they had bed capacity for.
In the early hours of 14 March, Mr K died despite the precautions and healthcare measures that were taken by the IPS. These included a number of medical assessments and 15-minute checks by Prison Officers through the glass panel in the cell door.
IPRT is concerned that after Mr K was found unresponsive after suffering a seizure, he was returned to his original cell on the A3 landing following discharge from hospital. The cell was not searched for hidden drugs. He was then moved to Cell 6 in the VPU where he later died.
While Mr K’s death in itself raises a number of significant questions and concerns, all of which are reflected in the OIP’s recommendations, IPRT is also extremely concerned at the events that happened in the aftermath of Mr K’s death. His cellmate in the VPU, referred to as Prisoner 1, who had found that Mr K was not breathing and raised the alarm, was not moved to another cell. Again, this may speak to how overwhelmed the prison is in terms of capacity. Prisoner 1 who was already vulnerable and self-harming prior to Mr K’s passing was then found unresponsive on three subsequent occasions on 14, 16 and 18 March and hospitalised twice before being returned to the same cell in Cork Prison. From the report it is our understanding that no sweep of the cell was completed despite two serious incidents taking place involving two different people identified by the IPS as vulnerable.
While the OIP commended the IPS on its swift and effective reaction to the apparent presence of Nitazene in the prison estate (see HSE Red Alert to prison settings issued at the time, March 2024), it was critical of its handing of Mr K and Prisoner 1’s cases. It stated that:
More generally, this case highlights the difficulties experienced by the IPS in effectively monitoring people living in prisons who may have been internally secreting drugs. It seems clear that relying upon the cell mates of such persons (if, as in the case of Mr. K, they are held in shared accommodation) to raise an alarm is not an adequate safeguard. Nor is visual observation by prison staff from outside cells always sufficient to detect a risk to life.
It went on to make eight recommendations, six of which the IPS has accepted or partially accepted including:
The development of an IPS Standard Operating Procedure (SOP) to ensure a thorough and immediate search of a cell following a suspected overdose to ascertain if any drugs remain hidden there.
That a person removed from a cell following a suspected overdose will not be returned to the same cell unless a thorough search of that cell has been conducted and fully documented.
A health-led approach with health care professionals taking the lead, to be followed if a person subject to a possible overdose is suspected of concealing drugs internally
If deemed necessary to isolate a person because they are suspected of internally concealing drugs or other contraband items, they should be subject to healthcare not security observation, including at night.
The IPS should explore the potential of employing remote monitoring of vital signs technology in prisons in Ireland.
When a person dies in a shared cell, all other occupants should be relocated to different cells immediately and should not be returned to the same cell where they have witnessed a death.
Again, IPRT notes the impact of the capacity and overcrowding issue across the prison estate, meaning that the IPS cannot fully commit to not returning someone to a cell where they have experienced a traumatic event like witnessing a death. It has stated that the new SOP ‘will provide for relocation of prisoners insofar as is operationally feasible’.
The IPS did not accept two further recommendations including review of a prisoner on return from hospital following a serious incident, by a prison doctor on their return to prison. The IPS response indicates that all people in prison have timely access to the prison healthcare team. However, with current pressures and waiting lists, IPRT contends that this is not always evident. IPRT is disappointed that the IPS has not accepted the recommendation to put in place a protocol between the IPS and the Health Service Executive (HSE) to ensure that medical treatment and adequate aftercare is provided to prisoners before they are returned to a prion setting. The rationale provided by the IPS is that ‘the HSE are statutorily responsible for providing prisoners with appropriate medical treatment and aftercare before returning them to a prison setting’. However, this would remain the case but IPRT supports this recommendation as establishing protocols between the two bodies could provide important safeguards and ensure that the necessary processes are clearly outlined and agreed, understood by all parties involved and implemented correctly through clearer communication and coordination.
We also note and commend the quick timeframe in which the OIP concluded its investigation into Mr K’s death and the relatively swift publication by the Minister of Justice. However, we note that the report references two other cases about similar deaths in custody of two other men – Mr C 2021 and Mr E 2021 in which the OIP made recommendations ‘to improve the handling of cases involving the suspected internal secretion of drugs’ and these were accepted by the IPS. However, neither Death in Custody report has yet been published as it is not within the gift of the OIP to publish its own reports. IPRT urges the Minister to immediately publish these and any outstanding reports submitted to her to date by the OIP.
IPRT extends its sincere condolences to the family of Mr K on their tragic loss. We hope that the recommendations made following his untimely death will ensure that other people in prison will be safer and that other families will not be bereaved in similar circumstances.
Respect for rights in the penal system with prison as a last resort.