Records relating to the supervision of a severely mentally ill Spanish resident who was found dead in his cell in Cloverhill Prison were falsified, a prison watchdog has found.
The Office of the Inspector of Prisons, which is led by Mark Kelly, was highly critical of how the Irish Prison Service (IPS) handled the detention of the deceased, whom it called “Mr O”, in 2022.
It determined Mr O was in custody on suspicion of a minor offence and was due to be transferred to a psychiatric hospital the day after he was found dead in a close-supervision cell on August 10th, 2022.
Prisoners under close supervision are supposed to be checked every 15 minutes. A prison journal recorded that staff had checked the prisoner at 7am, 7.15am and 7.30am.
However, Mr O had been found unresponsive sitting on the toilet in his cell at 6.50am, causing staff to issue a “Code Red” and call for an ambulance.
This “clearly” indicates the three journal entries had been filled in ahead of time by staff, “entirely negating the value of this recording safeguard”, the inspectorate said in a newly published report.
The inspectorate also noted “an (unsuccessful) effort had been made to erase the three entries”.
The statutory inspection body has raised concerns about the falsification of prison records on several previous occasions.
It echoed concerns contained in a recent report by the Council of Europe’s Committee for the Prevention of Torture (CPT) that found several cases of records being falsified.
The issue was particularly notable in Cloverhill and Limerick Prisons, where falsified records were discovered following several prisoner deaths in close-supervision cells.
The CPT said minimal action had been taken by local prison management to address this.
The Inspector of Prisons said it is “imperative” the falsification of records “is treated with the utmost seriousness” by management.
Regarding Mr O, it said he was detained on a public order charge at Dublin Airport on August 4th after he was observed acting erratically.
He was unable to take up bail after he was judged to be of unfit mind to sign the bond. In Cloverhill, his behaviour was observed as “bizarre and erratic”.
Staff reported he “was standing on his bed in a state of undress and shouting at the floor and refused to respond to questions asked by the nurse”.
Gardaí told prison staff the judge would strike out the charge against Mr O if treatment could be arranged.
Staff also learned he had spent time in psychiatric hospitals outside the State and had not been taking his medication for a lengthy period of time.
A place was found for Mr O in St Vincent’s hospital in Fairview. He was due to be transferred on August 11th. However, early on August 10th, he was found unresponsive in his cell.
Attempts to revive him were unsuccessful and he was pronounced dead at 9.45am. The inspectorate’s report does not detail a cause of death.
The inspectorate repeated recommendations that “urgent consideration” be given to quickly transferring mentally ill suspects charged with minor offences to local psychiatric hospitals.
“It remains unacceptable that prisoner-patients such as Mr O, suspected of minor offences, and suffering from a mental health disorder, cannot more rapidly access in-patient psychiatric treatment in local civil psychiatric hospitals.”
In response, the IPS said it is working on implementing several recommendations in this area and that additional resources are being assigned to Cloverhill.
Regarding the falsification of records, it said a “digitisation project” will commence later this year that will improve record-keeping and limit “the risk of falsification”.
It said staff who are found to falsify records “are sanctioned in line with the code of discipline”.
