Ireland’s statutory prisons watchdog, the Inspectorate of Prisons, has called for further action to reduce the risk of people in prison dying from overdoses.

The  call comes in an independent investigation report published today (19 July 2024) by Minister for Justice, Helen McEntee TD, setting out the Inspectorate’s findings regarding the death of “Mr. K” in Cork Prison on 14 March 2024.

The Inspectorate sent this report to the Minister within two months of Mr K’s death, in order to address the immediate risk of future deaths occurring in similar circumstances. The report commends the Irish Prison Service (IPS) for the rapidity and effectiveness of its reaction to the discovery of the apparent presence of Nitazene in Irish prisons in mid‐March this year. Had the IPS not reacted so swiftly and decisively on that occasion, the lives of other prisoners could have been placed in immediate jeopardy.

Nonetheless, the Inspectorate finds that the events leading up to the death of Mr. K and the very similar pattern evident in the events surrounding the repeated hospitalisations of his cellmate demonstrate that there is room for improvement in the handling of cases of this kind, both by the IPS and the HSE.

This report has been published a day after the Irish Prison Service issued a further urgent drug alert to all prisons, following HSE laboratory analysis which confirmed the presence of a Nitazene substance associated with overdoses in prisons (https://www.irishprisons.ie/drugalert/). One such apparent overdose may have led to a further death in a prison on 18 July 2024 and the Inspectorate is now investigating the circumstances of that death.

Speaking after the publication of the report, Chief Inspector Mr Mark Kelly said:

“The fact pattern in this case includes monitoring by the IPS of people living in prisons who may have been internally secreting drugs. It seems clear that relying upon the cell mates of such persons (if they are held in shared accommodation) to raise an alarm is not an adequate safeguard. Nor is visual observation by prison staff from outside their cells always sufficient to detect a risk to life. In order to enhance the effectiveness of the health care monitoring of such persons, the Inspectorate has recommended that the IPS explore the potential to employ remote monitoring of vital signs technology in prisons. I am pleased that the IPS has accepted, and is acting upon, this recommendation.”

The report contains another seven recommendations emphasising, in particular, the vital role that should be played by health care staff in monitoring people in this situation, including at night. The IPS has accepted three of those recommendations, partially accepted two, but has declined to accept two recommendations relating to the interface between hospital care and medical care in prisons. In the interests of minimising the risk of future deaths in similar circumstances, the Inspectorate considers that these two recommendations merit further consideration by the Department of Justice and the Department of Health.

The full text of the Inspectorate’s independent investigation into the death of Mr K 2024 is available here – [Mr. K 2024] and the Action Plan of the Irish Prison Service in response to the report is available here – Mr. K 2024 Action Plan .

 

Note to editors

The Office of the Inspector of Prisons (OIP) was established under the Prisons Act 2007 (the Act). Since 2012, the Chief Inspector of Prisons has been obliged to investigate all deaths in prison custody. This includes the death of any person which occurs within one month of their temporary release from prison custody. The OIP also carries out regular inspections of prisons.

The Office is independent of the Irish Prison Service (IPS). The Chief Inspector of Prisons and the staff of the OIP are independent of the Department of Justice in the performance of their statutory functions.

The OIP can make recommendations for improvement where appropriate. Our investigation reports are published by the Minister for Justice, subject to the provisions of the Act, in order that investigation findings and recommendations can be disseminated in the interest of public transparency, to promote best practice in the care of prisoners. In order to respect the privacy rights of the next of kin, the identity of a deceased prisoner is anonymised prior to publication.

The Inspectorate’s independent investigation into the death of Mr K 2024 in March 2024 makes the following eight recommendations:

  1. The OIP welcomes the IPS Drugs Strategy 2023 – 2026. In keeping with the objectives set out in that Strategy, it recommends that, in all cases where a prisoner is removed from his/her cell following a suspected overdose, a thorough search of the cell should immediately be conducted, in order to ascertain if any drugs remain hidden there. This search should be fully documented and information regarding the nature of any drugs found should be communicated to the prison’s healthcare team and, if the prisoner concerned remains hospitalised, to the hospital concerned. This requirement should be set out in an Irish Prison Service Standard Operating Procedure (SOP).
  2. Where a prisoner is removed from a cell following a suspected overdose, the prisoner concerned should never be returned to the same cell unless a thorough search of that cell has been conducted and fully documented.
  3. If it is suspected that a prisoner removed from a cell following a suspected overdose may be concealing drugs internally (for example, because no drugs have been found during a thorough cell search), health care professionals should take the lead in decision making regarding the supervision and care of that person. All such decisions should include a recorded risk assessment.
  4. If it is deemed necessary to isolate a person from the general prison population because of a suspicion that that they have internally secreted drugs or other items of contraband, they should be subject to health care, not security observation – including at night – irrespective of whether they are held in a Special Observation Cell (SOC), Close Supervision Cell (CSC) or separation cell.

In this regard, the Inspectorate endorses the view of the Council of Europe’s European Committee for the Prevention of Torture (CPT that the most effective approach would be to do away with the current differentiation between a CSC and a SOC and instead focus on the reasons for the placement of a prisoner in one of these cells.

  1. In order to enhance the effectiveness of the health care monitoring of such persons, the Inspectorate recommends that the IPS explore the potential of employing remote monitoring of vital signs technology in prisons in Ireland.
  2. In the event that a prisoner dies in a multiple-occupancy cell, all the other occupants of that cell should be immediately relocated to different cell. Prisoners should never be obliged to remain in, or be returned to, a cell in which they have witnessed a death. This should be made clear to Prison Governors by the Director General of the Irish Prison Service.
  3. All prisoners who attend hospital following a serious incident, such as a suspected drug overdose, should be medically reviewed by a prison doctor on their return to prison or at the earliest opportunity thereafter.
  4. It is frequently deemed necessary to remove a person from prison to hospital for medical intervention. The OIP recommends that protocols be established between the IPS and HSE to ensure that medical treatment and adequate aftercare is provided to prisoners before they are returned to a prison setting. Implementation of this recommendation will require close cooperation between the Department of Justice and the Department of Health.

* * *

In addition, the Inspectorate recalls that, in two other death in custody investigation reports submitted to the Minister for Justice and pending publication (Mr C 2021 and Mr E 2021), it has recommended a range of measures designed to improve the handling of cases involving the suspected internal secretion of drugs. The IPS has accepted the following recommendations, which apply mutatis mutandis in relation to the death of Mr. K 2024:

– The Irish Prison Service should introduce a health care focused policy to respond to the threats and safety risks posed by the internal secretion of drugs and other items of contraband. This policy should clarify the roles and responsibilities of management, prison officers, and healthcare staff;

– This new policy should provide for a central role for health care professionals in decision making regarding the supervision and care of a person where there is a suspicion of internal secretion of drugs and other items of contraband. All such decisions should include a recorded risk assessment;

– The Irish Prison Service should intensify its efforts to physically prevent contraband from entering the prisons and to detect its presence once on the premises, including through technological means.

ENDS