Overdose prisoner Patrick Kelly 'could have been saved'
An inmate at Maghaberry who died after an overdose could have been saved, a Prisoner Ombudsman's report has concluded.
The review found that prison authorities should have noticed that Patrick Kelly, who died in hospital last year aged 46, had been hoarding tablets.
Mr Kelly had been heavily dependent on medication for a number of years when he was jailed at the prison.
When remanded to Maghaberry, he asked that the authorities avoid giving him all his tablets because he was worried he might take them all at once.
The Ombudsman said: "Unfortunately his prophetic request was only briefly heeded."
Mr Kelly initially received his medication under a 'supervised swallow', but was allowed to go back to 'in possession' status four days later without any measures to prevent an overdose. Two days later, he was dead.
Prisoner Ombudsman Tom McGonigle said the nurse who "probably took the decision" to return Mr Kelly to in possession status said she had no recollection of doing so.
Two clinical reviewers retained by the ombudsman found Mr Kelly's committal experiences in February 2015 "were insufficient to keep him safe" and called his overdose "foreseeable" and "preventable."
While the emergency response to Mr Kelly's overdose on March 18, 2015, was praised, concerns about his medication management were raised. These included inconsistent prescribing practices, an 11-day delay in providing new prescriptions, and incorrect assumptions that his medication was being supplied and taken as prescribed.
Other issues centred around the committal process at Maghaberry. While Mr Kelly's previous health issues were highlighted in documents that accompanied him to the jail, prison staff and nurses overlooked them and relied on his self-reports and immediate presentation.
There was also a failure to recognise the significance of a forensic medical officer's assessment that he was at high risk of self-harm, and to share this information with colleagues.
Ombudsman Mr McGonigle said: "This poignant case has provided considerable learning about medication management.
"It is particularly difficult for his family to accept that Mr Kelly died from an overdose of his own medication after having asked not be allowed to hold it because he recognised the risks.
"I must yet again stress the importance of prison and healthcare personnel paying heed to information they receive from external agencies when someone arrives into prison, and sharing that information with all who need to know.
"The report makes 21 recommendations, which I trust will be used to improve the prospects for prisoners in future."
A spokesperson for the South Eastern Health and Social Care Trust said they accepted the findings and recommendations.