A catalogue of neglect – but no-one is held to account for the death of Samuel Carson

Prisoner Ombudsman Pauline McCabe /


A teenager who took his own life at Hydebank Young Offenders Centre was let down by the prison regime’s failure to prevent repeated attacks on him by other inmates, a Prisoner Ombudsman report has concluded.

Samuel Carson was 18 years-old when he was remanded to Hydebank Young offenders Centre on March 6, 2010.

The Co Antrim teenager and a friend had initially been charged with the alleged rape of a 15 year-old girl.

Prisoner Ombudsman Pauline McCabe found that while the rape charges against the 18 year-old had been dropped before he took his own life, the authorities at Hydebank had failed to take account of the reduced charges and he continued to be attacked by other inmates as a sex offender.

Mrs McCabe described the bullying which the teeanger endured while being held in Hydebank as one of the worst cases she had ever investigated.

The report into yet another suicide in one of Northern Ireland’s prisons comes just months after the Detail revealed in an article the abnormally high use of solitary confinement against inmates being held at Hydebank.

It is the latest in a long line of investigations which have criticised the Hydebank regime.

In an interview with the Detail in June 2011 the families of Samuel Carson and Frances McKeown, who also took her own life in Hydebank on the same day, revealed concerns over the treatment of inmates in the south Belfast prison.

Despite acknowledging the efforts of Justice Minister David Ford and the Prison Service’s new director Sue McAllister, Mrs McCabe says she believes that bullying at the young offenders centre remains a major problem.

“If you’re asking me on the back of Samuel’s death do I believe that there has been a significant change in connection to this, then the answer to that is that no I don’t,” she said.

“If you’re asking me am I satisfied that today nobody would be bullied at Hydebank Wood, that is absolutely not the case…I believe that efforts are now being made and there is a commitment to dealing with it, but I do believe we have a lot of work still to do.”

Read extracts from extended interview with Prisoner Ombudsman Pauline McCabe.

The Prisoner Ombudsman report into the death of Samuel Carson found:

• Numerous recorded instances of the teenager being subjected to serious threats which were never investigated by prison authorities.

• Hydebank’s security staff and some prison officers regarded the bullying of alleged sex offenders as `inevitable’.

• Investigations of bullying were ineffective. Evidence on occasions that staff failed to stop bullying – despite orders to do so.

• Investigations of bullying against the teenager were abandoned when he withdrew complaints – even though staff knew this was because he feared further attack.

However no member of the Prison Service is to be disciplined for the failures of the Samuel Carson case.


Hydebank inmate Samuel Carson /

Samuel was Sylvia Carson’s only son.

As a teenager he’d planned to join the British army and had gone through the recruitment process but had abandoned those plans when his girlfriend gave birth to a baby boy.

Samuel’s girlfriend later recalled how he’d phoned her in tears after being charged with rape.

He’d never been to prison before being remanded to Hydebank.

Because of the sexual nature of the offences he was judged by prison governors to be “vulnerable and at risk”.

Prisoner Ombudsman investigators found that the threats against Samuel began within days of his arrival in Hydebank but there was no record of anything being done by governors to address the issue.

After two weeks spent on a committal wing after entering the prison Samuel was moved to Elm landing.

Prison officers told ombudsman investigators that the teenager should never have been moved to Elm.

One warder recalled that Samuel was under “constant danger of attack by other inmates” who threatened “we’re gonna cut your throat”.

Another reported how the teenager had “coped well on the committal landing but (his mood) deteriorated when moved to Elm 3… Samuel is not coming out of his room… (he) stated that he had thoughts of suicide last week and had took out his laces from his shoes.”

A prison counsellor recalled how the teenager had struggled to cope with the constant threats from other inmates.

“He stated that night time is the worst and stated he doesn’t know if he will be able to cope until next week,” when he was due to apply for bail.

However investigators could find no evidence that prison governors took action to address the bullying.

In a letter to his mother Sylvia, he wrote:

“I’m here nearly two weeks now and I’m getting it bad in here getting called rapist and getting threatened that I’m gonna get sliced up, I’m feeling really low in here…my head’s going worse than it was… if anything happens to me in here I love yous all…”

He confided to his solicitor that he’d been attacked by other inmates using “pool balls placed in a sock” but was too afraid to make an official complaint.


Hydebank Prison /

Samuel was later released on bail but found himself still being targeted on the outside.

He was beaten by a gang while staying with his sister.

Samuel and his partner had to be taken into emergency accommodation after being warned by police that he was under threat from paramilitaries.

The couple secured another rented property but the landlord refused to rent them the accommodation after being contacted by police.

The landlord later told investigators:

“I received a telephone call from a police officer whom I believe was part of the prosecuting team. The officer explained that the reason why he was ringing was due to child safety and he was concerned about whether Samuel would be in the presence of children… he further said that Samuel Carson was accused of serious charges relating to child abuse. Lastly, he also informed me that my address was (to be) used as a bail address.” The landlord said that after he heard about Samuel he “googled” him to find out more details of his offences and that “based on the information from the police officer and the information I found on him, I decided not to rent the property to him. This was on the basis that Samuel had failed to be wholly open and honest with me.”

The constant threats and the fact that he could not find a suitable bail address meant Samuel was forced to return to Hydebank.

Within days of being back in prison he began to self-harm as the threats from other inmates resumed.

A prison nurse recalled: “He states that last night the other inmates were planning to attack him today and he stated that he felt that he could not take this anymore and felt that he had no option but to superficially scratch his arm.”

On 20 August 2010 Samuel became a father for a second time after his girlfriend gave birth to a baby girl.

But because of the sexual nature of the charges against him social services ruled he should not be allowed to see his new baby daughter.

This led to a serious decline in Samuel’s mental health, with staff reporting:

“He is going to hang himself no matter what. He is getting hassle on the landing from other inmates ref his charge. He can’t get a bail address and social services have told him that he cannot see his baby daughter (four days old) or his son. States he has had enough.”

Despite these warnings Samuel wasn’t seen by mental health authorities for the following seven months before his death.

In August 2010 Samuel reported being bullied by three other inmates while being held on the Willow landing.

Weeks later he slipped a note under his cell door to a prison officer, pleading:

“Sir can you make a note in the office in the morning not to open my door cause the other inmates are saying they’re gonna punch the head off me in the morning…. (Three inmates names redacted) said they’re gonna get me when the cell door opens.”

A senior prison official stated that as other inmates refused to co-operate “it was (Samuel’s) word against theirs”.

An investigation into the threats concluded: “Either Carson is granted his request to move to another landing or the three individuals are separated and moved to other landings. However the latter course of action may result in further adverse consequences for Carson."

The report was forwarded to an anti-bullying unit but there was no record of any action being taken.

Samuel continued to be kept on the same landing as the three alleged bullies.

However serious questions have been asked as to whether the Hydebank regime took the threats against Samuel seriously.

The prison’s security department, which is meant to protect vulnerable prisoners, recorded: “There is no previous information about these particular inmates bullying Carson.

“It is thought that Carson may be trying to manipulate the system.”

Samuel subsequently made an official complaint over the failure to deal with his complaint but was beaten up a day later, suffering a broken nose.

In his complaint he wrote: “I brought the bullying to the staff’s notice which something should have been dealt with right away but due to that they (inmates) were (given) a chance which I ended up with a broken nose and marks in my face and lumps on my head under my hair which was caused by them smashing an ashtray over my head. If action was taken when I brought it to the staff for the second time I would not have been attacked. I am very unhappy.”

A senior prison official substantiated the complaint stating: “He had made two complaints of being bullied, naming the same inmates on both occasions. Now he has suffered an assault by the two alleged bullies.”

In November 2010 the Public Prosecution Service informed Samuel’s solicitor that the rape charges against him and his co-accused were being dropped but that he would still face lesser charges.

Hydebank prison inmate

Hydebank prison inmate

Despite this the prison regime failed to update Samuel’s prison record to indicate the rape charge had been dropped.

However in a subsequent letter to his mother Samuel admitted that the attacks against him were continuing: “You get treated better if you come in here for murder.”

He told one warder that there was a “bounty on my head” with inmates being offered drugs and tobacco to attack him.

Despite the obvious threat, Hydebank’s security unit reported: “with regards to location there is little that can be done to ensure Carson’s safety as he is… suspect to attack anywhere.”

When he was moved to another wing, other inmates claimed he was being rewarded for being a “tout.”

One prison officer told ombudsman investigators that he’d warned prison chiefs on two separate occasions that the teenager was going to be attacked stating: “Things were getting tense between Samuel Carson and other inmates.”

The officer said he was told that his concerns had been noted, but that Samuel wouldn’t be moved on the “word of one officer.”

The warder told superiors: “You know what’s going to happen. I’ve done all that I can.”

In March 2012 Samuel’s solicitor again raised concerns about “severe bullying and attacks by inmates” and threatened legal action over the “inadequate approach taken by the prison to protect Mr Carson.”

Weeks before he died a female officer on night duty reported how Samuel had passed notes under his cell door asking to speak to the Samaritans.

However when another inmate realized that Samuel was passing notes under his cell door, he shouted: “What’s you doing touting? Is he touting on us miss?”

She described the abuse directed towards Samuel as “severe” and how the inmate had shouted: “You scumbag, what did you tell her?”.

A warder recalled how the following day Samuel had admitted: “Last night was the worst night of abuse he had endured since he had been in Hydebank.”

Days later Samuel was hospitalised after being assaulted by two inmates which left him coughing up blood with multiple bruising to his head, face and rib cage.

When one of the inmates involved was later questioned, he told a warder: “Sure you have no evidence, no CCTV, no forensics, nothing.”

The threats increased further when seven inmates blamed him for informing on them taking drugs in his notes to warders.

In fact the notes had only contained Samuel’s fears for his safety.

A security report stated: “Inmate Carson has now quite a collection of listed enemies and it is difficult to keep him totally safe.”

Ombudsman investigators found that the only action order to be taken was for the names of two inmates to be added to Samuel’s list of enemies.

This was never done.

Female prisoners moved to Hydebank Wood from Maghaberry in 2004

Female prisoners moved to Hydebank Wood from Maghaberry in 2004


However the fear that social services may never allow him to see his children again may also have played a role in Samuel’s death.

One warder recalled how the teenager’s girlfriend told him that social services had warned that their daughter may be taken into care if she continued to keep in contact with him.

The officer recalled how Samuel had been “most distressed… anxious and concerned…. in Samuel’s world he had plans set to settle down as a family unit, and such a decision by social services certainly impacted on him.”

On May 3, 2011 – the day before his death – Samuel had written a letter in preparation for a case conference with social workers scheduled for two days later.

In the letter Samuel wrote that he’d stopped taking drugs and agreed to take part in whatever rehabilitation classes social workers recommended in order that he should be allowed to see his baby daughter.

“Am I allowed to live with my daughter in the future as there is nothing more in the world that matters to me? I would do anything to have and be a proper family,” he wrote.


On May 4, 2012 Samuel was visited by one of his sisters, who later told investigators that he hadn’t appeared unhappy or under stress.

He later ate lunch with other inmates before returning to his cell for afternoon lock-up.

A prison warden found Samuel hanging in his cell at 5.05pm.

Several inmates and prison officers told investigators that they didn’t believe that Samuel had intended to take his own life and that it may have been a cry for help which ended in tragedy.

One officer who was on duty that day, stated: “Samuel could have assumed that he was being unlocked at the point (another inmate) was locked in his cell, as the sound of the doors locking and unlocking are very similar.

“Samuel may have then tied the ligature around his neck for attention and assuming that someone would check upon him shortly after the `unlock’ when in effect it was actually someone being locked up.”

However another inmate stated: “I think he took his life cos of bullying and he missed his family and he didn’t go to the gym or education because he feared he would get sliced.”

Prisoner Ombudsman Pauline McCabe said that it was impossible to rule out the possibility that Samuel’s death had been a cry for help which had ended in tragedy.

“It is possible that Samuel expected to be found before he died,” she said.

“Whilst it is not possible to conclude this with certainty, the timing of his death might suggest that this was the case.

“Whether or not Samuel intended to die, the question remains as to what, on the evening of May 4, 2011, resulted in him taking the action he did.

“As reported, Samuel had been extensively bullied and assaulted during his time in prison. Whilst there was clear evidence that this affected him and, at times, made him frightened to leave his cell, he had never previously made such a serious self-harm or suicide attempt.”

However Mrs McCabe said that on the night prior to his death Samuel had again been the victim of repeated taunts from other inmates.

“It is one possibility that, after months of verbal and physical bullying, Samuel decided that he could not take another night of the same abuse.”

She said the repeated attacks on the teenager were the result of a combination of factors.

“The investigation found that much of the bullying to which Samuel was subject to by other inmates was linked to the nature of the charges that led to him being remanded in custody.”

Investigators found that despite the rape charge against Samuel having been dropped governors at Hydebank had failed to downgrade his risk as a sex offender.

However she also found that the attacks had taken place because some inmates’ mistakenly believed that Samuel had been passing on information about them.

“There was, however, also evidence that Samuel was bullied because some inmates believed he was a “tout” and had provided information to security about inmates. This was believed to be, in part, because of a misunderstanding resulting from Samuel passing notes back to staff when he was concerned for his safety.”

Investigators found that Samuel had in fact supplied information to prison officers on other occasions but that not enough had been done to protect his security from attack from other inmates afterwards.

The 28 areas of concern identified by Mrs McCabe regarding Samuel’s death included:

• Numerous recorded instances of Samuel being subjected to serious threats which were never investigated.

• Investigations of bullying were ineffective. On a number of occasions there was no evidence that staff took steps to stop the bullying – despite being ordered to do so.

• Numerous allegations of bullying were never referred for investigation.

• Bullying investigations were abandoned when Samuel withdrew complaints – even though staff knew this was because he was afraid of further attack.

• Hydebank’s security staff and some prison officers regarded the bullying of alleged sex offenders as `inevitable’.

On March 26, 2012 Samuel’s co-accused was cleared of all charges after the Public Prosecution Service failed to enter any evidence against him at the opening of the trial.

Samuel’s case was never heard.

Read the full Prisoner Ombudsman’s report into the death of Samuel Carson here.