Finding out what went wrong is key to preventing future tragedy


I NTERVIEW:Proper investigation of deaths in prison offers an opportunity to see where reform is needed

THE ABSENCE of independent investigation into prison deaths is denying the Irish Prison Service the opportunity to reform and is minimising public and political pressure on it to do so, Northern Ireland’s Prisoner Ombudsman Pauline McCabe has said.

In an interview with The Irish Times ahead of her appearance at an Irish Penal Reform Trust conference in Dublin this morning, she said her office’s investigation into deaths in Northern Irish prisons had forced many systemic changes in the prison system there.

The publication of her reports into prison deaths had, she believed, also created the public and political pressure needed to drive change in any part of the public sector.

“It also informs decision makers like our political representatives; they are the policymakers, the people who decide if we are going to commit to reform and finance it.”

“Crucially, it informs the public. There wouldn’t be much appetite in the North for prison reform. But for a lot of people, when they read some of the detail of specific reports, they start to think about, what we’re doing [within the prison service].”

She said the thorough investigation of prison deaths represented the best opportunity possible to interrogate prison practices and make reforms when needed.

“Usually when there is a death in custody, particularly a death by suicide, you find a whole number of things that may have contributed,” she said.

“The point is that if you don’t do that [independent] investigation and get to the bottom of all of the different issues, then the opportunity [is lost] to put those things right and prevent future serious incidents and deaths.”

She added that finding out why and how a prisoner had taken their own lives – or, in a smaller number of cases, had been murdered – in jail often provided proof of a need for reforms that was so strong it could not be ignored.

“You are finding out what went wrong: what went wrong in terms of committal processes; what went wrong in terms of drug administration; what the access to illicit substances [was]; what did you do when someone had mental health problems; who helped them and supported them when they needed it.”

“The answers to all of those questions are the key to preventing future tragedy, but [you] also [provide] a much more rehabilitative regime in the future by fixing those things.”

McCabe’s office investigates complaints from prisoners about any aspect of their treatment and conditions in jail.

She and her staff also investigate all deaths in custody, drawing up reports with recommendations, all of which are published.

Investigations are completed and reports published within a year of a prisoner’s death.

She told The Irish Times such speed was vital to prevent future tragedies in as far as possible and also to provide information to grieving families who often knew little of their loved one’s last hours in prison.

While the PSNI still investigates murders in prisons, the Prisoner Ombudsman reviews those findings and can make recommendations arising from them.

In the Republic, there is no prisoner ombudsman or any similar agency that carries out independent investigations into prison deaths.

When prisoners die by suicide in the Republic, these cases are investigated internally by the prison service. However, the findings of those inquiries are never released and the procedures for conducting such inquiries have never been published.

Gardaí fully investigate prison murders. However, unless the case goes to court, no aspect of those investigations is made public, save for basic facts at the prisoner’s inquest.

While all deaths in prison are subject to an inquest, these are often delayed for many years in the Republic with no explanation, or obligation to explain, on the part of the Irish Prison Service.

In the North, Prisoner Ombudsman staff visit a jail within four hours of a death and take control of a scene for examination. They also take any physical evidence away with them.

The ombudsman staff can seize CCTV recordings from the prison in question and can access the recordings of any phone calls made by the deceased in the days and weeks before their death, as well as accessing medical files.

A quick review of evidence is carried out over the fortnight following a death with a view to identifying any major issues that need to be addressed immediately by the prison service.

In some cases the ombudsman’s office has found that prisoners on suicide watch were not being monitored every 15 minutes as they should be. Instead, prison officers were smoking and playing cards and, in some cases, even sleeping when working overnight.

McCabe said exploring the minutiae of deaths in prisons and publishing the often damaging findings had driven significant change in the North across a range of areas – from prison staff training to prison security and healthcare systems reform.

“People will tell you time and time again that [reforms] are happening and then the death in custody actually gives you the hard evidence that they are not happening the way they should be.”

She also said the practice of confining prisoners to lock-up in cells for up to 23 hours a day – an increasing trend in the Republic – was “the enemy of the vulnerable” and only served to reinforce criminality and the personal issues that led to it.

McCabe was this morning due to address an Irish Penal Reform Trust event – Prisoner Rights and Prisoner Complaints Mechanisms – in the Chester Beatty Library, Dublin Castle.