A jury has called for an independent review of all medical care at Cork Prison after it returned a verdict of suicide in the case of a 29-year-old father of two who took his own life while in an isolation cell at the prison during the Covid-19 pandemic.
The jury of four men and two women took over an hour at Cork City Coroner’s Court to return a verdict of suicide at the inquest into the death of Andrew Gearns from Parkway Drive, Model Farm Road, who died at Cork University Hospital on October 7th, 2020.
Mr Gearns had been found unresponsive in his cell at Cork Prison on September 28th and the jury returned the verdict of suicide, finding that Mr Gearns died from hypoxic ischemic encephalopathy or global brain injury due to cardiac arrest due to suspension by a ligature.
[ Prisoner showed no sign of delusional behaviour until the eve of taking his own life, inquest hears ]
The jury also said it wanted to endorse four recommendations by the Office of the Inspector of Prisons in an anonymised report on Mr Gearns’ death. This report identified him only as Mr K, but laid out clearly what it felt the Irish Prison Service needs to do to try to prevent any similar deaths.
In particular, it endorsed a recommendation regarding the handover of prisoners from Gardaí to prison staff.
The Inspector of Prisons recommended that the Prison Service should introduce a Person Escort Record, including details of all known risks of self-harm, to be completed for every movement of a prisoner into or out of a prison either by Prison Service Staff or by members of An Garda Siochana.
The jury also endorsed another recommendation that a prisoner’s previous history of self-harm recorded in the Prison Service’s Risks and Alerts system should also be recorded on the separate Prison Information Management System.
All prison staff with a duty of care to that prisoner, including the prison governor, should be aware of the existence of such information, said the Inspector of Prisons and the jury also backed this after hearing prison staff were not aware of a previously recorded attempt by Mr Gearns to self-harm.
They also urged the Prison Service to urgently fix a glitch in their Information Technology system, after hearing that details entered for Mr Gearns’ previous committals were transferring to the most recent committal form, meaning that out-of-date information was showing up on the system.
And the jury also called on the Department of Justice, the Prison Service and the Inspector of Prisons to urgently address delays in the compilation of the Inspector of Prison reports after hearing that it took almost two and a half years to publish the report on Mr Gearns’ death.
The investigation into Mr Gearns’ death involved the examination of many hours of CCTV footage from the B1 Normal Landing and the jury also recommended that 72 hours of CCTV footage relating to a prisoner’s committal be retained instead of the proposed retention of just 48 hours of footage.
Cork City Coroner Philip Comyn thanked the jury for their diligent consideration of the evidence and their recommendations.
Mr Comyns commended Mr Gearns’ family for their commitment to ensuring they got as much information as possible about what happened to their son before sympathising with them on their sad loss, while he also acknowledged that Mr Gearns’ death had been difficult for Cork Prison staff.
During the inquest, the jury heard evidence that Mr Gearns had become addicted to drugs after he was prescribed benzodiazepines following a car crash in 2016 and that he was using heroin, buying methadone on the street while his relationship with his partner had also ended.
After the inquest, the family of Mr Gearns said that his life could have been saved if his medical history was properly checked and he had been assigned to a special observation cell rather than a regular cell when he was committed to Cork Prison.
“We welcome all the recommendations made by the jury, but we particularly welcome and agree with the call for an independent review of medical care at Cork Prison – if Andrew’s medical history had been properly checked, we believe that his life could have been saved,” said his brother, Evan.
The inquest had heard Mr Gearns had not been assessed as high risk on arrival at the prison even though the family believed that he had attempted to take his own life two years earlier while in garda custody in April 2018 and Mr Gearns’ disclosure of the episode was logged on the prison records.
Speaking after the jury returned their verdict at Cork City Coroner’s Court on Friday, Evan Gearns, flanked by his mother Aideen and sister, Jemma, expressed his frustration at some of the system failings that came out at the inquest and were highlighted by the Office of the Inspector of Prisons.
The family believe that checks on Mr Gearns should have been more extensive during his time in prison.
Mr Gearns said that it had taken the family over two years to get the inquest held due to the staff shortages in the Cork City Coroner’s Office while it had taken just as long to get the Office of the Inspector of Prisons to publish his report on what happened to his brother in Cork Prison.
“We had to fight for everything – to get the inquest held because of staff shortages, to get the Inspector of Prisons report, even to get Andrew’s medical records through an FOI – these are basic things that we should be able to get without having to fight for them,” he said.
“We know the coroner doesn’t have the power at the moment to ensure recommendations are put in place but that should be done and sooner rather than later because lives are being lost in prisons all over the country – it’s too late for Andrew but if his death could save one life, it would be good.”
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