Family of man who died in prison distressed over two aspects of case

He shouted abuse, clenched his fists, growled at the members of An Garda Síochána. He resisted arrest. One of the gardaí pepper sprayed him. It had no effect. He took off, wandered across a stream. The gardaí followed. They pepper sprayed him a second time. Still no effect. They tried a third time.

Eventually, Mr Blackwell was taken into custody.

He was brought to Bantry hospital for treatment. There, he tried to grab a scissors from a doctor and threw blood on a wall.

Two weeks later, he appeared before Judge James McNulty at Skibbereen

District Court. The court was told that Mr Blackwell was originally from the UK and had lived in Cork for the previous 13 years. He’d had a few scrapes with the law. One incident involved the robbery of an axe from a domestic home.

When questioned about it, he said he had been “looking for a game of darts”.

After hearing the details, Judge McNulty said: “He has smoked far too much weed and he has fried his brains, or cooked them to a stage where it is on the ‘well done’ side.”

He sentenced Mr Blackwell to two three-month prison terms for resisting arrest and the incident at the hospital respectively. The sentences were to be served consecutively, amounting to six months imprisonment.

Within three months, Mr Blackwell would be found dead in Cork Prison.

Whether somebody of his obviously fragile mental health should have been in prison at all is a question that has dogged the criminal justice system for decades.

A more pressing question surrounds how somebody of his fragile physical health was taken care of in a secure setting.

Initially, the prison service claimed it had done all it could do, followed the regulations, performed the duty of care. Then CCTV footage emerged which disputed this claim and raised questions about how this death was handled, and whether it points to a bigger issue around deaths in Irish prisons.

‘Bizarre behaviour’

Following his visit to Bantry hospital on October 13, Mr Blackwell was brought to Cork Prison. On admittance he was medically examined. The nurse’s notes portray a man in some disarray.

“Unkempt appearance, blood on shirt, left thumb has dressing in place, breakthrough bleedings…bizarre behaviour observed in holding cell, appears to be interacting with unseen stimuli, encouraged to shower with little success,” wrote the nurse, who recommended that Mr Blackwell be placed in a safety observation cell to be seen the following day by the prison doctor and psychiatrist.

Both examined him. The psychiatrist noted:

Patient lying on floor demanding cigarettes. Uncooperative, physical health gives rise to concern… Orientated re date but not time — get background — concern re hydration.

Later that day, Mr Blackwell was taken to the emergency department of the Mercy Hospital in Cork to have his left thumb sutured. When he returned he was placed in a Vulnerable Persons Unit (VPU).

Over the following five weeks, Mr Blackwell was seen by medical staff — either doctor, nurse or psychiatrist — every few days. On November 6, a nurse recorded him as “pacing and making fists, staring at the prison radio” and asking staff if they saw “lights/orbs passing through his cell”.

On November 11, medical staff recorded that he was seeing “orbs” in his cell and that he was “stable but unpredictable”.

For the next two weeks, Mr Blackwell was seen daily by the nursing staff and had eight consultations with the prison doctor and two with the psychiatrist.

On November 29, the psychiatrist recommended that he could be placed in the general prison population on a trial basis. Things went OK for Mr Blackwell for the following month.

Then, on January 2, a deterioration in his mental health was noticed. A prison officer observed that he was “acting very strangely”, that he was “sitting cross legged in the middle of the cell floor, with a duvet wrapped around his wrist”.

He refused to come out of his cell for dinner. During the recreational period that afternoon, he also stayed put. A decision was taken to transfer him back to the VPU.

Just before 6pm, he was visited by a nurse. He stated that Mr Blackwell was “lying just inside the cell door on his left side with his head propped up with his left hand”.

After attempting to interact with him, the nurse recorded that the prisoner “was in a psychotic state of mind and was mentally deteriorating to the point of relapse”.

It was now obvious that the prisoner was in a highly vulnerable state. The standard operating procedure (SOP) in Cork Prison states that every prisoner in the VPU “must be checked every 15 minutes”.

This SOP applies to all staff, including healthcare. Yet, this was not done in the case of Mr Blackwell. CCTV footage, recovered and observed by the Inspector of Prisons, show that there were long gaps between checks that evening.

For instance, nobody checked on the prisoner between 7.26pm and 9.08pm.

And there was a further gap of 97 minutes before the next check.

Then there was a gap of 51 minutes before Mr Blackwell was next visited at 11.38pm.

At that time, the Assistant Chief Officer (ACO) for the night shift was making his rounds. He noted that Mr Blackwell was on the floor of the cell under a duvet.

That of itself was not unusual for this prisoner, but the ACO tried to get Mr Blackwell’s attention without success. Following that, he decided to investigate and entered the cell. Mr Blackwell was unresponsive. Medical staff were called and then paramedics were summoned in an attempt to resuscitate him but all to no avail. Mr Blackwell was pronounced dead at 1.20am.

Conflicting records

The cause of death was acute congestive heart failure. It may be that Mr Blackwell’s condition was such that any intervention in the hours or minutes before he died would have been futile. One way or the other, the Irish Prison Service was bound to look after his interests while he was in their care. A significant feature of that duty was that Mr Blackwell was to be observed at 15 minute intervals after he was transferred to the VPU on the day of his death.

The official written record showed that he was examined regularly as per the operating procedure.

The acting Inspector of Prisons at the time, Helen Casey, examined the medical observation cell book for the day in question. She also examined the CCTV footage from the same period. The written record and the footage were in conflict.

The record certifies that 15-minute checks were carried out from 16.30 to 19.15 and from 20.00 to 23.15. It is obvious from viewing the CCTV footage that these entries are incorrect and misleading.

The footage, as noted above showed gaps of 102 minutes, 97 minutes, and 51 minutes in checks in the hours before Mr Blackwell’s body was discovered.

Ms Casey reported that, “but for the CCTV footage viewed, I would have accepted the written record as representing compliance with the SOP”.

She made a number of recommendations into her report on the death of Mr Blackwell (He was not identified in the report).

• “When the status of a prisoner is documented as ‘special obs’ this must be taken seriously as it suggests an element of vulnerability. Prison personnel, of all grades must be aware that the management of ‘special obs’ prisoners carries a high degree of responsibility and must ensure that the Standard Operating Procedures are complied with.”
• “All prison personnel must appreciate that official documents must reflect the truth of actions taken by officers.”
• “Prison staff must understand that it is a serious matter to generate official documents that are misleading and/or inaccurate.”

The inquest into Mr Blackwell’s death took place on April 11. Prison officer Tim Sexton was on duty in the VPU on the night Mr Blackwell died. In his deposition, he stated that he had performed the 15-minute checks. The inquest was shown the prison logs which recorded that the 15-minute checks had taken place.

The prison officer told the inquest that he was confused and upset when he gave his deposition.

“I have saved numerous suicides,” he said. “This was the first time a prisoner died in my care.”

Under further questioning, Mr Sexton said that he had never been shown how to fill out the observation log sheet and that Mr Blackwell’s name wasn’t on the list of observation inmates. He also said there was “possibly a lack of communication with night staff”.

The jury returned a verdict of death due to natural causes and made no recommendations.

Frank Buttimer, the solicitor for Mr Blackwell’s family, told the Irish Examiner that the family are particularly distressed about two aspects of the case.

“They are distressed about the failure to properly attend to their father’s needs when he was alive and they are also very distressed about what seems to them to be the falsification of records about the checks that were supposed to be made on their father on the night he died.”

David Blackwell had been due for release on March 9, 2018. Just over two months after he died.

Concerns about deaths in custody not included in report

Last August, the Irish Examiner published an analysis of reports compiled by the inspector of prisons which showed that more than two-thirds of deaths of vulnerable persons since 2012 produced concerns about “misleading” or inaccurate record keeping by prison staff.

Joe Leogue wrote: “In some cases, log books stating that special-observation inmates, or ‘special obs’, were checked every 15 minutes, as per protocol, were proven to be not true when the inspector reviewed CCTV footage of the time in question.

“The Office of the Inspector of Prisons made its first finding of incorrect record-keeping in a 2012 report on the death of a prisoner in Mountjoy.

“Similar issues have since been noted in reports into deaths in Cork, Limerick, Portlaoise, Cloverhill, and Wheatfield Prisons.” The problem highlighted in Joe Leogue’s report is widespread. It reflects the low level of concern felt in sections of the service for vulnerable prisoners, bereaved families, and safe and satisfactory procedures or duties.

All of these are apparently regarded as secondary to the main consideration that no blame or stain attach to any member of the service for shortcomings.

In a 2014 report, then-inspector Judge Michael Reilly noted how one prison officer had said that, in training, staff are told that when writing reports, they are to “keep it short and cover your arse”.

In another report that year, Judge Reilly referenced a statement he was furnished with from a prison officer following a death in custody.

In a number of my investigations I have found such statements to be minimal in content, misleading, and in certain cases inaccurate,” he said.

Last October, Assistant Chief Officer David McDonald swore an affidavit in which he alleged a number of instances of malpractice within the Irish Prison Service (IPS). One issue of concern he had was around deaths in custody. Mr McDonald said he had brought his concerns to Judge Reilly, who died in December 2016.

Mr McDonald swore in the affidavit that there were “no protocols or procedures in place for the preservation of the scene where the death occurred”.

“I was aware on certain occasions that that cell was not preserved, the body was moved and if there was another prisoner in the cell with the deceased person he would be moved to another cell,” he said.

As a result of his growing concern over what was happening, Mr McDonald “undertook a training course in Templemore in relation to the taking of DNA samples. I also introduced evidence bags and other procedures for the proper retention of evidence relating to the death of a prisoner.

“I also gave courses to other staff so they would know how properly to deal with the circumstances surrounding a death in custody, how to preserve evidence and ensure statements were taken from all relevant persons including prisoners and staff.” Mr McDonald stated that he found his enthusiasm to professionalise the response to deaths in custody was not shared by management.

When this paper published details of the affidavit last November, Minister for Justice Charlie Flanagan ordered an inquiry by the Inspector of Prisons into elements of it. (The report was completed and is now with the Attorney General).

However, the concerns related to deaths in custody were not included in the commissioned report.

Last May, then-director of the IPS, Michael Donnellan, told the Oireachtas Justice Committee that the management of people with severe and enduring mental illness posed a serious problem for the service. At that time, the service had recorded that 323 people from an overall prison population of 4,000 were deemed to have been suffering from severe mental illness.

“The use of imprisonment is inappropriate for people with severe and enduring mental illness as prisons are not therapeutic environments,” Mr Donnellan told the committee.

Evidence was also heard that mental health issues are particularly acute among young people in custody. At the Oberstown detention facility for young people there were mental health concerns about 23 of the 50 residents.

Professor Harry Kennedy of the National Forensic Mental Health Service told the committee that four children at the facility at that time were on anti-psychotic medication.