Prison watchdog criticises lack of progress following jail deaths

Tom McGonigle is the third prisoner ombudsman to hold the post since it was established in 2005

Tom McGonigle is the third prisoner ombudsman to hold the post since it was established in 2005

By Niall McCracken

THE watchdog for Northern Ireland’s prisons has claimed “repeated failures” by government to implement recommendations following deaths in custody has led bereaved families to question the role of his office.

There have been 48 deaths in jails here since the creation of the Prisoner Ombudsman’s office in 2005.

But in a letter written to Stormont’s Justice Minister and Health Minister in November, the ombudsman highlighted his “increasing concern” that changes are not being made following prison deaths and have led families to “question the benefits of prison oversight”.

Prisoner Ombudsman Tom McGonigle added: “I am sure you will understand the frustration felt by families of deceased prisoners when they learn that we find it necessary to repeat such recommendations”

In the letter, obtained by The Detail, he wrote: “The need to repeat these recommendations indicates individual failings at managerial and operational levels, and possibly also systemic failings.”

Figures highlighted by Mr McGonigle show that despite being accepted by prison authorities at the time, over 30% of the recommendations made in the last 10 death in custody reports had previously been made.

Some of the recommendations dated back to 2008 and featured issues including the abuse of illicit and prescription medication, inadequate record keeping of healthcare staff and failure to comply with Supporting Prisoner at Risk (SPAR) procedures.

The Department of Justice has overall responsibility for the Northern Ireland Prison Service (NIPS) while the South Eastern Health and Social Care Trust (SEHSCT) oversees prisoners’ healthcare.

Justice Minister David Ford and Health Minister Jim Wells replied separately to the ombudsman’s letter at the end of November 2014 stating they wanted to assure him that steps were being taken to address the issues he had raised, including reviews of prison healthcare and the self harm policy.


The Northern Ireland Prisoner Ombudsman’s Office was established in 2005 under pre-existing prisons’ legislation and therefore has never had its own statutory basis.

There has been an ongoing campaign by successive to grant the office its own statutory footing in order to increase its independence and grant it more power in terms of gaining access to confidential documents central to the office’s investigations.

The primary role of the prisoner ombudsman is to investigate deaths in custody. The office will also investigate some post custody deaths, cases defined as a “near death in custody” and prisoner complaints.

In 2010 the Hillsborough Agreement outlined that the prisoner ombudsman’s office should have its own statutory footing in order to fully establish itself as an arms length body, separate from government, and to demonstrate its independence from the prison service.

Five years on this has yet to be fully implemented. However following a consultation last year the Department of Justice said it intends to legislate for these proposals within the forthcoming Fines and Enforcements Bill by the end of the current Assembly mandate in April 2016.

In an interview with The Detail, Tom McGonigle said he is keen to eliminate any concerns about his office’s independence.

He said: “I’m the third prisoner ombudsman who has had the notion of placing this office in statutory footing since it was established ten years ago.

“The prisons’ legislation, which we are currently set up under, is not an appropriate place for this office. Our own statutory footing would mean the perceptions of this office in terms of its independence would be heightened which is very important.

“From a practical point of view it would be easier for me to recruit my own staff in terms of investigators for this office, which is a very specialist role, but also information sharing with authorities would be more straightforward.

“For example at the minute we can only access those records from the South Eastern Trust when we acquire next of kin consent. The trust, as with other statutory bodies, has more confidence in dealing with another statutory body and will make the process of them agreeing to share such information with us much easier.”


In his letter to the Justice and Health Ministers, dated November 2014, the ombudsman underlined his “increasing concern” about the number of repeated recommendations his office has had to make following a number of death in custody reports.

An analysis by the ombudsman’s office of the last ten death in custody reports from April 2013 to October 2014 found that from a total of 126 Prisoner Ombudsman recommendations, 39 (31%) had previously been made and were accepted by the NIPS and SEHSCT.

Twenty-two recommendations made to the NIPS were repeated, and 17 recommendations to the trust were repeated. Two of the 126 recommendations were jointly made to the NIPS and the trust.

In his letter to the ministers, the ombudsman stated:

“The need to repeat these recommendations indicates individual failings at managerial and operational levels, and possibly also systemic failings. There has been good practice by NIPS and trust staff, and improvement in certain areas. However the progress is undermined by repeated failures to implement recommendations that were accepted.

“I am sure you will understand the frustration felt by families of deceased prisoners when they learn that we find it necessary to repeat such recommendations. It also leads them, and other prisoners, to question the benefits of prison oversight.”

In a response letter from November 2014 the Justice Minister, David Ford, stated that a Senior Governor had been seconded to prison headquarters to address a number of issues raised by the ombudsman including the NIPS Suicide and Self Harm policy and the approach in respect of substance misuse.

Meanwhile in a separate letter the Health Minister Jim Wells outlined that the SEHSCT had commenced a review of prison healthcare services to include management structures and patient care pathways in prisons.

All correspondence can be viewed in full at the bottom of this article.


Tom McGonigle has been Prisoner Ombudsman since June 2013 /

In concluding his letter – which was released to The Detail following a request to the ombudsman’s office – Mr McGonigle said the theme of repeated recommendations featured in two forthcoming death in custody investigations.

At the end of last year The Detail reported on a case where prison authorities were warned by police about the fragile mental state of a young inmate only hours before a suicide bid that claimed his life.

Police records for 20-year-old Joseph Rainey stated that he was “suicidal” and “had depression” before being handed over to Hydebank Wood Young Offender’s Centre in April 2013, but within hours he was rushed to hospital with life threatening injuries.

In an interview with The Detail, his parents Tom and Sarah raised questions about whether or not prison authorities could have done more to prevent his death.

A prisoner ombudsman report into Joseph Rainey’s death is expected to be completed in the near future.

In their interview with The Detail Joseph’s parents said that there were a number of issues they wanted addressed by the ombudsman to ensure that what happened to their son could not happen again.

Prisoner Ombudsman policy in relation to death in custody reports states that the preference is to publish the report in full in order to serve the public interest.

However Mr McGonigle said that it must also balance the public interest against legal obligations in respect of data protection and privacy, as well as taking account of the views of the next of kin on publication.

The office can offer to anonymise reports and redact dates or other identifying information if a report is to be published.

The ombudsman’s office said that since the current ombudsman took up post in June 2013 it has published six death in custody reports.

Mr McGonigle said that two separate reports were not published because of commitments given by the previous ombudsman.

Of the six reports that Mr McGonigle published over the last 18 months, four were anonymised.

He defended the need to balance the reporting of the human cost of each case, against legal and data protection concerns.

“My approach to death in custody reports is very clear, my preference is that we publish and that is in the public interest. However I must balance that very carefully against the wishes of next of kin and the experiences that they have had through a death in custody process, which is quite often very stigmatising for people and difficult enough to cope with.

“Journalists would have very serious questions for me and my office if I were to publish a death in custody report against the wishes of a family.

“The full report goes to the family, the prison service, the trust and the coroners’ service, so those who need it for statutory purposes will have it. The families will also have it to inform them in detail about what happened before they lost their loved one.

“Thereafter, we’re not in the business of providing, sorry to say – information for journalists to feed stories. A human face is entirely appropriate but we have to balance that extremely carefully and those are challenging decisions and judgements that we must make.”

The prisoner ombudsman currently has three prison death and six post-release deaths or near death investigations ongoing.