There is “learning” to be done by the Northern Ireland prison service and a local health trust, the interim prisoner ombudsman has said following a report into the death of a man in custody.
Jacqui Durkin has also said it is “essential” prisoners with mental and physical health needs are given appropriate support and assessments.
Her comments follow the publication of the findings of an investigation into the death in Maghaberry Prison of Kenneth Ramage.
The probe has led to two recommendations being made to the prison service and the South Eastern Health & Social Care Trust.
Mr Ramage (47) died on 18 September 2020 after being brought into custody four days earlier.
He was in custody at four different periods in 2020, serving two of these sentences during the Covid-19 pandemic.
In June 2020, he was admitted to Maghaberry where a committal risk assessment and mental health screenings were carried out.
But on June 2 he was found unresponsive in his cell and transferred to hospital.
The report found Mr Ramage confirmed he had attempted to end his life and staff put a care plan in place.
On June 7, he returned to Maghaberry and was referred to the addictions team before being placed on supervised administration for his medication.
He was released on July 17, but returned to custody on 14 September 2020, where a committal risk assessment was completed and he was found to be at “no apparent risk” of self-harm or suicide.
Further assessments were carried out and Mr Ramage was deemed to be “unsuitable for in-possession tablets”, but was permitted to keep his insulin pens in cell.
The report found that on 17 September, Mr Ramage received his medication and 11 checks were carried out by the night custody officers between 7.30pm and 7am on 18 September.
Mr Ramage was found unresponsive by landing staff at 8.47am.
He received medical assistance, but was pronounced dead at 9.24am.
The Independent Clinical Reviewer concluded that the care Mr Ramage received in Maghaberry was to standard and considered as equivalent to, or of equal standard to, that provided in the wider community.
The prisoner ombudsman agreed with the findings, and was satisfied Mr Ramage’s mental state and thoughts of self-harm were discussed and challenged at each relevant encounter.
The report made two recommendations, one for prison service on committal calls procedures, and one for the Trust on healthcare in prison committal procedures.
Ms Durkin also noted a previous recommendation on the need for review on how information related to the risk of suicide or self-harm is shared to ensure prison officers have the information needed to respond appropriately to individuals in custody and their behaviours.
A spokesperson for the NI Prison Service said: “Any death in custody is a tragedy and the NI Prison Service extends its sympathy to the family of Mr Kenneth Ramage who died in Maghaberry Prison on 18 September 2020. The Prison Service considers the content of any death in custody report carefully and has accepted the single recommendation of the Prisoner Ombudsman in this case.
They added: “The Prison Service continues to review its processes and procedures and works closely with healthcare colleagues in the response to people who self-harm. Working collaboratively, the aim is zero suicide within our prisons.”
A spokesperson for the South Eastern Trust said it would “like to extend its deepest sympathies to everyone who knew and loved Kenneth, at what must be an extremely distressing time”.
They added: “The Trust welcomes the prisoner ombudsman’s recommendation as an opportunity to learn and improve the service for all those in our care.”
