Death in custody investigation
At an immediate meeting of the inspector Patricia Gilheaney with the prison authorities, it was decided that a death in custody investigation was warranted.
Relevant material was provided in a timely manner, the report says, but lacked detail. Interviews with staff members did not take place until November due to staffing issues in the Office of the Inspector of Prisons.
The prisoner was committed on 20 June 1985, aged 20, and had been transferred around many prisons during his 33 years in custody, making 29 moves. He was also hospitalised on several occasions due to poor health.
Diagnosis
In December 2017, he was given a diagnosis of months to live, and was put on palliative care. Massive weight loss was noted by a doctor the same month. At the time of death, he was on 14 different medications.
In 2014, parole board reports said he had made progress in developing relationships with his estranged family, following the death of his mother.
He was described as a well-behaved model prisoner who engaged positively with staff and management.
However, some temporary releases led to aggressive behaviour and alcohol abuse, but family and graveside visits were also recorded.
In December 2017, the prisoner had been transferred from Shelton Abbey to Portlaoise, due to a lack of medical care at the former.
On 12 June, a doctor directed that the prisoner be urgently transferred to hospital as soon as possible, as he was complaining of severe pain.
No escort
Seven hours later the notifying officer was informed the prisoner had not been transferred. She contacted the detail office and was informed that staff shortages meant there was no escort available for the transfer.
It was agreed that the transfer could wait until the morning. However, no doctor was consulted before this deferral was agreed and the medical instructions overridden.
The officer agreed to the suggestion because she considered the prisoner had not been complaining or in distress. This opinion was at odds with the views of two carers who believed he was in "extremely bad shape".
The following morning the prisoner sounded his alarm bell and complained of feeling unwell. The nurse officer then found him lying on the floor in distress and pain.
Collapsed
He was not transferred ‘first thing’ but not until he was found in a collapsed state at 10.40 am.
The inspector says there was still no indication of preparations to take him to hospital. A doctor then attended the prisoner and an ambulance was called. The prisoner was moved to a local hospital at 11.10am, then transferred to St James hospital in Dublin at 4pm.
The report complains of a lack of urgency in dealing with the ill man.
Next-of-kin details were also recorded incorrectly which led to delays in informing them of the situation. One telephone number was incorrect and the other defaulted to an answering machine.
The Irish Prison Service (IPS) did not attempt to contact the family for over seven hours, despite hospital staff requesting notification immediately on the prisoner’s arrival. The report calls this “poor practice”.
The family was ultimately notified by local gardai, shortly before the prisoner died at 1.40am on 14 June.
The IPS subsequently contributed the maximum amount specified in its inmate funeral policy of €2,000.
A sum of €100 was also allocated for clothing the deceased but there was a breakdown in communicating this to the inmate’s daughter, who felt aggrieved at having to arrange and pay for his funeral, despite his incarceration when she was just an infant.
The family was upset that no prayers were said at the funeral home but expressed their gratitude to the prison chaplain who attended, as the prison governor’s representative.
Good practice
The inspector notes that good practice was adhered to during the prisoner’s brief stay in St James. The report notes that previous care of the prisoner included provision of a wheelchair and carers, and treatments including medication, dietary adjustments and surgery.
Failure to transfer him urgently to hospital was a ‘major failing’, the report says.
Staffing shortages were given as the reason the man’s transfer to hospital was delayed. Efforts to have the man released on license, in light of his diagnosis of months to live, had been unsuccessful.
The Inspector sets out the need for a review of the application of compassionate release policies for terminally-ill people “in order to avoid the indignity of dying in prison”.
The report recommends improved recording of evidence in death in custody cases and says all significant incidents must be fully detailed and specific.
The principle that ‘if it was not recorded, it was not done’ should be applied in future training, the report says.
Competence of staff
The IPS should also satisfy itself about the competence of staff involved in the failure to follow a doctor’s orders and make sure that no repeat occurs.
When hospital transfers are delayed, nursing and medical checks should be increased, it says.
The Irish Penal Reform Trust (IPRT) said in a statement that it was gravely concerned about the case.
“Considered against Council of Europe guidance, these failings may have amounted to inhuman and degrading treatment,” according to IPRT.
The body has called on by justice minister Helen McEntee to ensure that the current Prison Health Needs Assessment is expedited and findings published by the end of 2020.
It also wants transfer of responsibility for prison healthcare from the Department of Justice to the Department of Health.
Executive director Fíona Ní Chinnéide said: “The failure to bring a terminally-ill man in severe pain from Ireland’s biggest prison to a hospital across the road due to operational reasons is not acceptable.
Tragic case
“This tragic case highlights a number of systemic issues. Not only was the deceased not transferred to hospital urgently as requested by the prison doctor, but his next of kin were not informed of his critical state, despite requests from hospital staff, until shortly before he died.
“The man had not been granted compassionate release to a palliative care setting, and he had been moved from an open prison back to a closed prison so that his medical needs could be managed. The Inspector does note that the man had received appropriate medical management for his diagnosis from the prison service up to 12 June 2018.
“This is not the first time that a prisoner in Ireland has died shortly after delays in transfer to hospital due to non-medical staffing issues.
“It is absolutely paramount that the life, health and dignity of men and women in the custody of the State are the priority consideration. The report echoes comments by the former Inspector of Prisons, who stated in 2015 that the provision of healthcare to prisoners should not be dependent on operational considerations.”
'State of crisis'
Following its visit to Ireland in 2014, the European Committee for the Prevention of Torture (CPT) described healthcare in some Irish prisons as being “in a state of crisis”.
The Committee specifically highlighted the deterioration of healthcare services in the Midlands prison, and the need to address gaps in escort provision to ensure that prisoners receive medical attention in the community, the IPRT points out.
The Inspector’s report found that 54 hospital appointments had been cancelled due to staffing shortages in the Midlands Prison that year according to prison records.
Council of Europe guidance on prison healthcare is clear that the normal prison environment is harmful and amounts to inhuman and degrading treatment for some prisoners, including those with terminal illness.
The guidance states that terminally-ill prisoner patients should be allowed to die in freedom and dignity, and without pain; legal and administrative arrangements must be in place to facilitate this.