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Care fell short for sick prisoner who died: Ombudsman

The standard of care given to a prisoner who died at Maghaberry Prison “fell short” of expectations, the Prisoner Ombudsman has concluded.

An investigation into the death of Stephen Patrick Doran (69) in June 2008 found that deterioration of his condition, which included chronic pulmonary disease, was “not properly recognised” and said monitoring was “inadequate”.

Mr Doran was seriously ill and according to one nurse he was “a very sick man” when he was remanded in custody on June 2, 2008 to await trial after being charged with 39 counts of indecently assaulting a male. He spent five days in the prison healthcare system but died on June 6, 2008.

An autopsy carried out on established the cause of death as pneumonia, chronic bronchitis and emphysema.

In her report Ombudsman Pauline McCabe said the Northern Ireland Prison Service and the South Eastern Health and Social Care Trust had accepted that Mr Doran’s care and treatment had been below standard and made eight recommendations to improve the care of seriously ill people committed to Ulster jails.

“My primary aims are to inform the Coroner of my findings and to make recommendations which will help prevent similar deaths in future at Maghaberry or elsewhere in the Northern Ireland Prison Service,” she said.

“Mr Doran was in a poor state of health when he was committed to Maghaberry and he was immediately transferred to the prison health care centre, where he died four days later.

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“Following a thorough investigation informed by the opinion of a highly qualified independent medical expert, I am making eight recommendations relating to the care of seriously ill people in prison.”

The Ombudsman’s recommendations include reviewing the circumstances under which a prisoner should be transferred to an outside hospital, reviewing arrangements of recording to vital signs and reviewing the capability to carry out night time clinical observations.

A South Eastern Trust spokeswoman said: “The Trust accepts the recommendations outlined in the report and all of these are being implemented. A service improvement board has been put in place in Maghaberry Prison to develop and drive forward the quality of healthcare services in prison.”

The Prisoner Ombudsman is currently investigating another 10 custody deaths.

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