David O'Driscoll jail death report finds failings in Maghaberry
The mother of a man who killed himself in prison called staff to raise concerns about his welfare hours before he died.
David O'Driscoll (30) passed away in a cell at Maghaberry Prison in August 2016.
He was found dead by staff just seven hours after arriving at the high-security jail.
An investigation found issues around staff handovers, record-keeping and access to medication.
The report, published today by interim Prisoner Ombudsman Brendan McGuigan, said Mr O'Driscoll had been remanded into prison following two periods in police custody between August 10 and 12, 2016, on charges including contravention of a non-molestation order, assaulting police and criminal damage.
Medical records had indicated a history of deliberate self-harm and overdoses.
A few hours before his death, Mr O'Driscoll's mother had telephoned the prison to raise concerns about her son's welfare after he had called her and threatened to kill himself.
After making enquiries, the day manager on duty at Maghaberry returned Mrs O'Driscoll's call and reassured her that her son was fine. Mr O'Driscoll died later that evening.
The investigation identified that no one had spoken directly to Mr O'Driscoll about the call he had made to his mother's home, and the reassurance given to Mrs O'Driscoll was based on earlier interactions an officer on the committal landing had with him.
Speaking about the report, Mr McGuigan said: "It is clear that some aspects of Mrs O'Driscoll's telephone call could have been managed better and there was no evidence that a number of measures the manager asked to be put in place were completed.
"The investigation identified an inadequate handover from prison service day staff to night staff and poor record keeping, which regrettably is a recurrent finding in Prisoner Ombudsman death in custody investigations."
A clinical review also raised potential concerns around the continuity of Mr O'Driscoll's access to medication from his time in custody.
The report makes 11 recommendations for improvement; most have been accepted by the Prison Service and South Eastern Health and Social Care Trust.
The head of the Northern Ireland Prison Service, Ronnie Armour, said: "I want to extend my sympathies to David's family. I very much appreciate how difficult the findings of this report will be for them, and on behalf of the Prison Service I want to apologise for the fact that David died in our care.
"It is important to recognise the difficult and challenging circumstances that prison staff encounter every day. In the last year alone, prison officers at Maghaberry Prison have saved 12 lives.
"However, today's report clearly highlights the events leading up to David's death and, in doing so, rightly focuses on a number of failings in our procedures.
"I want to assure the family that we have, and will continue to learn from this tragedy."