Recommendations made following death of inmate in Midlands Prison

A number of recommendations were issued following an investigation into the death of an inmate at the Midlands Prison in Portlaoise. 

The 26 year-old man was found unresponsive in his cell in the Midlands Prison on July 17, 2023.  He was pronounced dead at the Midlands Regional Hospital, Portlaoise a short time later.

The man, referred to in the report by the Office of the Inspector of Prisons as Mr L, had spoken to his sister earlier that day and she told inspectors that she had no cause for concern at the time and she expressed disbelief at what had happened. 

Mr L had moved to the cell two days earlier having moved from another landing. His cell mate said the pair had played on the Xbox after their lunch at 12 and then he remained in his cell when it was opened for recreation at 2.10pm. He told his cellmate said Mr L wanted to stay in the cell to make a phone call. 

An officer who was reopening cells for returning inmates at around 3.30pm noticed a cell call light flashing and found the inmate in an unresponsive state in the cell at 3.36pm. He raised the alarm and called for a Hoffman knife to cut a ligature, but another officer had difficulty unlocking a safety box to access the knife and the ligature was ripped free. 

Prison nursing staff and two doctors responded to the alarm at 3.38pm and one of the doctors examined the man and said he was “gone” at that stage.  

“Despite this assessment, the prison medical staff continued to attempt to resuscitate Mr. L until ambulance personnel took over Mr. L’s care,” the report notes. 

“Mr. L was in the process of being moved from the prison landing to an ambulance, by a stretcher, when there was an electrical fault with the landing elevator. A national incident report form documented that at 16:24 an electrical switch tripped causing the elevator, which was carrying Mr. L and the paramedics, to stall, trapping the occupants inside. The delay is reported as lasting for approximately five minutes,” the report stated. 

“Officer F escorted Mr. L to hospital and she stated that they left the Midlands Prison at 16.35. Officer F’s account confirms that Mr. L received treatment upon his arrival at the Midlands Regional Hospital, Portlaoise, however he was pronounced dead a short time later at 16.48,” according to the report. 

It noted that the officer who found the deceased in his cell had attended the cell “some 38 minutes after the cell call button was first activated” and that the light outside the cell had flashed before going solid red for a number of minutes before flashing again.

This prompted inspectors to carry out a test on the cell call system.  “Based on the test, it would appear that Mr. L’s cell call button had been activated, then accepted in the Class Office but not attended to for more than half an hour until Officer B began unlocking cells,” the report stated.   

“Officer B was asked about the cell call activation relating to cell 14 on 17 July 2023. He stated that he was not aware that the cell call button had been activated as he was performing his other duties, which included involvement with the movement of prisoners. Officer B stated that the Control Room did not notify him that the cell call button had been activated and that he would never intentionally ignore an alarm,” the report stated. 

Five recommendations were made in the report by the Office of the Inspector of Prisons. 

The report noted the importance of timely response to cell call activation had been highlighted after a prison death in Cork in 2021.  “It recommends that the IPS draw up a national Standard Operating Procedure regarding cell call notifications, including a national standard in relation to cell call response times. The IPS (Irish Prison Service) should also devise a system for monitoring compliance and regular testing of all associated equipment across the entire prison estate,” it stated. 

It recommended that the IPS develop and implement a national service-wide Suicide Prevention Policy and Strategy. It also recommended a SOP (Standard Operating Procedure) on safely removing incapacitated persons from cells with limited space should be developed.

It recommended that Prison Officers be reminded of their obligation to examine equipment in their area of responsibility and report any defects which could compromise good order, safe or secure custody or health and safety. This regular check should include verifying that the Hoffman knife safety box is accessible. 

Mr L was the fifth death of a prisoner from the Midlands Prison in 2023 and the twelfth death in IPS custody that year.

The Office of the Inspector of Prisons has an information pamphlet for relatives and friends of someone who dies in the custody of a prison. Further information can be found on the OIP website at www.oip.ie