Suicide-risk prisoner had not been checked for nearly an hour when he died

Officers had to use a lighter to burn through ligature as knife could not be found


A prisoner at Mountjoy Prison who was on a special observation regime after 11 suicide attempts or self-harm incidents had not been checked for nearly an hour when he took his own life.

The 21-year-old was found unresponsive in his cell in the Dublin prison in the early hours of December 4th, 2014. He never regained consciousness despite CPR efforts.

Prisoners on special observation are supposed to be checked every 15 minutes. A review of CCTV footage from the night showed 53 minutes elapsed between the last check on the prisoner and the time he was found.

On two occasions during that period, a prison officer walked past the man’s cell without looking in. On five other occasions during that morning and the previous evening, periods of between 28 minutes and 62 minutes elapsed between checks.

When officers did realise what was happening, a “code red” was called and staff rushed to the man’s cell. The knife to cut through a ligature could not be found and an officer was ordered to use his lighter to burn through the shoelace.The findings are contained in a report into the death by the then acting inspector of prisons, Helen Casey.


Ms Casey found officers did not abide by the protocols for special observation prisoners and there were failings in the man’s mental health treatment.

She also recommended that prison management assess clothing and footwear provided to prisoners at suicide risk because items such as laces and drawstrings can be easily adapted for ligatures. Additionally, a Hoffman knife – a specialist blade used to cut ligatures – should be located in the same place on all prison landings to make it easier to locate, she said.

The man was serving a 3½-year sentence and was due for release in September 2017. Medical records showed he had “poor coping skills surrounding environment and grievance process” but showed no evidence of major mental illness or suicidal thoughts.

He was addicted to prescription medication and at one stage was taking 30-40 tablets a day. He told medical staff the drugs increased his desire to self-harm and that he wanted to get clean.

Set fire to cell

Three months before his death, on September 4th, he attempted suicide or self harm three times in one day.

Incidents of self-harm continued over the following months despite multiple attempts to provide psychological help. He also set fire to his cell on one occasion.

After several incidents the man said he had self-harmed or attempted suicide in protest at various grievances, including the introduction of screened visits and because he wanted to go on a drug treatment programme.

On one occasion he said he attempted suicide, not because he wanted to die, but to prove to officers he could kill himself if he wished.