As you are on a mobile or tablet device you may not see the full table below on your device’s screen. However, you can rotate your device or scroll across the table below to view all the content.
| Date of Publication | Date of Death | Facility | Primary Keyword | Secondary Keyword | Recommendation ID | Investigation Type | Recommendation | IPS Response | Date of IPS Action Plan | IPS Action Plan | IPS Recommendation Owner | Timeline | 2025 Assessment Date | 2025 Assessment Type / Status | 2025 Status Update Information | Q2 2024 Assessment Date | Q2 2024 Assessment Type / Status | Q2 2024 Status Update Information | Q1 / Q2 2023 Assessment Date | Q1 / Q2 2023 Assessment Type / Status | Q1 / Q2 2023 Status Update Information | Q2 2022 Assessment Date | Q2 2022 Assessment Type / Status | Q2 2022 Status Update Information | 2020 Assessment Date | 2020 Assessment Type / Status | 2020 Status Update Information | Recommendation & Status Update |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 19/03/2026 | 21/02/2024 | Cloverhill Prison | Healthcare | 2024D1 | Death in Custody | The OIP has repeatedly highlighted the dangers of nursing under-staffing at night, especially in large committal prisons such as Cloverhill. Mr D experienced an – ultimately fatal – medical crisis at night, while the one nurse on duty was intermittently otherwise engaged in reviewing new committals in reception. These are precisely the kinds of circumstances that have previously led the OIP to recommend that nursing cover at night in Cloverhill Prison be increased. It recommends that the IPS ensure that a minimum of two nurses are on duty in Cloverhill Prison every night. | Acceptecd | 13/03/2026 | The Irish Prison Service review nursing cover at night as part of the Joint Task Review process. This process is ongoing across the Estate. | Care and Rehabilitation | Ongoing | |||||||||||||||||
| 19/03/2026 | 21/02/2024 | Cloverhill Prison | Healthcare | 2024D2 | Death in Custody | Another potentially life-saving measure that has been repeatedly recommended by the OIP is that all prison staff, including recruit prison officers, should receive cardiac first responder training. This recommendation has been made in a number of OIP death in custody reports, including the report on thedeath of Mr. I 2019 but has yet to be accepted by the IPS. Noting that this issue was also highlighted by local management at the Critical Incident Review Meeting following Mr D’s death, the OIP calls upon the Director-General of the Irish Prison Service to implement this recommendation | Not Accepted | 13/03/2026 | The referenced response in Mr. I 2019 is maintained by the Irish Prison Service. The below information was also provided in Mr. I 2019:Considerations for rolling out First Responder training were also based on the principle of equivalency. The response time from the prison healthcare team to a prisoner is likely to be much less that the response time from the HSE to an ambulance call-out.First responder training is provided to Gym Officers, PSEC Staff and Open Centre staff. It should be recognised that in the prison setting, a nurse is one of the first members of staff on the scene in an emergency situation. Basic Life Support and First Responder Training is a core element of the skillset of all nurses employed in the prison service. | Director General / HR (IPSC) | Closed | |||||||||||||||||
| 19/03/2026 | 21/02/2024 | Cloverhill Prison | Healthcare | 2024D3 | Death in Custody | The IPS should improve its procedures for the monitoring and supervision for prisoners who show signs of serious medical decline, especially if they exhibit symptoms such as difficulty breathing, distress, or a history of requesting medical attention repeatedly. Continuous health care observation of prisoners with worsening health could lead to quicker recognition of the severity of the issue. This should include a standardised emergency response procedure for airway obstruction and respiratory distress; if a respiratory issue cannot be not dealt with by providing a prescribed inhaler, a nurse should monitor the prisoner and, if no rapid improvement is discernible, a doctor should be called or a transfer to hospital arranged. | Accepted - Already in Place | 13/03/2026 | The Irish Prison Service Healthcare team provide 24/7 care to all prisoners in custody. Continuous observation and emergency responses are provided for as required | Care and Rehabilitation | Closed | |||||||||||||||||
| 19/07/2024 | 14/03/2024 | Cork Prison | Safety | Healthcare | 2024K2 | Death in Custody | Where a prisoner is removed from a cell following a suspected overdose, the prisoner concerned should never be returned to the same cell unless a thorough search of that cell has been conducted and fully documented. | Accepted | 23/05/2024 | See response to recommendation 1. | Operations Directorate | Summer 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 19/07/2024 | 14/03/2024 | Cork Prison | Healthcare | Narcotics Detection | 2024K3 | Death in Custody | If it is suspected that a prisoner removed from a cell following a suspected overdose may be concealing drugs internally (for example, because no drugs have been found during a thorough cell search), health care professionals should take the lead in decision making regarding the supervision and care of that person. All such decisions should include a recorded risk assessment. | Accepted | 23/05/2024 | Procedures for the management of prisoners suspected of internally concealing any prohibited article or substance and associated healthcare interventions are included in the redrafted SOP for Close Supervision Cells. The formation of a new healthcare SOP document underpinning the redrafted CSC SOP to cater for prisoners suspected of internally concealing contraband has begun. This will include a risk assessment carried out by healthcare staff and a treatment plan determined by this assessment which will include healthcare monitoring of the prisoner and eliciting a response from the prisoner overnight. It should be noted that the final decision on supervision is a statutory power reserved by the Governor of the prison . | Operations & Care and Rehabilitation Directorates | CSC SOP June 2024 Healthcare SOP Q3 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 19/07/2024 | 14/03/2024 | Cork Prison | Healthcare | Narcotics Detection | 2024K4 | Death in Custody | If it is deemed necessary to isolate a person from the general prison population because of a suspicion that that they have internally secreted drugs or other items of contraband, they should be subject to health care, not security observation – including at night – irrespective of whether they are held in a Special Observation Cell (SOC), Close Supervision Cell (CSC) or seperation cell. In this regard, the Inspectorate endorses the view of the Council of Europe’s European Committee for the Prevention of Torture (CPT that the most effective approach would be to do away with the current differentiation between a CSC and a SOC and instead focus on the reasons for the placement of a prisoner in one of these cells. | Partially Accepted | 23/05/2024 | See response to recommendation 3. | Operations & Care and Rehabilitation Directorates | Jun-24 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 19/07/2024 | 14/03/2024 | Cork Prison | Healthcare | Narcotics Detection | 2024K5 | Death in Custody | In order to enhance the effectiveness of the health care monitoring of such persons, the Inspectorate recommends that the IPS explore the potential of employing remote monitoring of vital signs technology in prisons in Ireland. | Accepted | 23/05/2024 | A sub-group of officials in the IPS has been established to examine remote monitoring of vital signs technology. The group has met with European colleagues and further discussions are planned. | Care and Rehabilitation/Operations/ICT Directorates | Ongoing | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 19/07/2024 | 14/03/2024 | Cork Prison | Mental Health | Death in Custody | 2024K6 | Death in Custody | In the event that a prisoner dies in a multiple-occupancy cell, all the other occupants of that cell should be immediately relocated to different cell. Prisoners should never be obliged to remain in, or be returned to, a cell in which they have witnessed a death. | Partially Accepted | 23/05/2024 | Where a prisoner dies in a multioccupancy cell, it is standard practice that all other prisoners are removed from the cell and the cell is then master locked pending an investigation by AGS. The IPS SOP referenced in the response to recommendation 1 will provide for relocation of prisoners insofar as is operationally feasible. | Operations Directorate | Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 19/07/2024 | 14/03/2024 | Cork Prison | Healthcare | Narcotics Detection | 2024K7 | Death in Custody | All prisoners who attend hospital following a serious incident, such as a suspected drug overdose, should be medically reviewed by a prison doctor on their return to prison or at the earliest opportunity thereafter. | Not Accepted | 23/05/2024 | All prisoners ordinarily have timely access to the prison healthcare team. Doctor referrals are made as required. | Care & Rehabilitation Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 19/02/2024 | 06/05/2024 | Cloverhill Prison | Standard Operating Procedures | Healthcare | 2024N1 | Death in Custody | Nurse Officers should ensure, when completing Nursing Committal Forms, that all fields are completed and that any obvious physical abnormalities are noted on the Nursing Committal Form. Forms should be completed at the time of the Nursing Committal interview with retrospective entries made only when absolutely unavoidable | Accepted - Already in Place | This is the requirement as per protocol standard practice. The requirement to adhere to protocol has been addressed as part of Continuing Professional Development (CPD) for Healthcare staff. | Care & Rehabilitation | Closed | |||||||||||||||||
| 19/02/2024 | 06/05/2024 | Cloverhill Prison | Healthcare | 2024N2 | Death in Custody | In the event of a prisoner declining or refusing medical attention or a medical hospital referral, a declaration to that effect should be signed and dated by the prisoner, counter signed by the clinician, and the form retained with their medical records. A refusal to sign should be recorded by the prison doctor/nurse on PHMS. | Accepted - Already in Place | This is the requirement as per protocol standard practice. The requirement to adhere to protocol has been addressed as part of Continuing Professional Development (CPD) for Healthcare staff. | Care & Rehabilitation | Closed | ||||||||||||||||||
| 19/02/2024 | 06/05/2024 | Cloverhill Prison | Policy & Procedure | 2024N3 | Death in Custody | One officer should always be present in the rear of the cellular vehicle at all times while a prisoner(s) is being transported (as per the IPS Escort Policy). This will make it easier for continuous visual monitoring of a prisoner in transit. | Accepted - Already in Place | This is a requirement under the IPS Escort Policy. Prison management address non compliance with this policy under the Civil Service Disciplinary Code | Operations | Closed | ||||||||||||||||||
| 19/07/2024 | 14/03/2024 | Cork Prison | Healthcare | 2024K8 | Death in Custody | It is frequently deemed necessary to remove a person from prison to hospital for medical intervention. The OIP recommends that protocols be established between the IPS and HSE to ensure that medical treatment and adequate aftercare is provided to prisoners before they are returned to a prison setting.Implementation of this recommendation will require close cooperation between the Department of Justice and the Department of Health. | Not Accepted | 23/05/2024 | The HSE are statutorily responsible for providing prisoners with appropriate medical treatment and aftercare before returning them to a prison setting. | Care & Rehabilitation Directorate | Complete | |||||||||||||||||
| 18/02/2026 | 18/07/2024 | Mountjoy | Standard Operating Procedures | Narcotics Detection | 2024Q1 | Death in Custody | Where there are reasonable grounds to believe that a particular prisoner is intoxicated, a prompt and proportionate search of their person and their cell should be conducted in line with established security protocols. If multiple prisoners present with similar symptoms of intoxication, a general search of cells should be considered. Operational guidance should clarify the threshold for initiating such searches and emphasise the importance of timely action to prevent harm. | Accepted - Already in Place | Rule 53 allows for a prisoner and cell to be searched at any time. The Governor determines the escalation from a cell to a wing, to the whole prison - based on the threat presenting and ultimately resources and the impact on the prison day. A General Search SOP cannot capture a level of threat or need for a hugely timeconsuming General Search - common sense and available intelligence are the determining factors. However, the Governor of Operations will issue a reminder that relevant cells should be searched as a matter of course following the intoxication of prisoners. | Operations Directorate | Ongoing | |||||||||||||||||
| 18/02/2026 | 18/07/2024 | Mountjoy | Standard Operating Procedures | Narcotics Detection | 2024Q2 | Death in Custody | From a preventive standpoint, it is crucially important that prison management and healthcare staff have rapid access to reliable information about the composition of any drugs found in a prison. Samples of drugs found in prisons should be swiftly analysed and the results communicated to prison management and healthcare staff in a timely manner. The OIP welcomes the rapid action that was taken by the IPS in this case. The OIP would add only that if the analysis is conducted by, or on behalf of, An Garda Síochána, clear channels of communication between the IPS and AGS should ensure that the results are equally quickly made known to prison management and healthcare staff. | Partially Accepted | Analysis of contraband is available in circumstances associated with an adverse clinical outcome only. This is available through the National Drugs Treatment Centre | Care & Rehabilitation and Operations | Closed | |||||||||||||||||
| 18/02/2026 | 18/07/2024 | Mountjoy | Security | Narcotics Detection | 2024Q3 | Death in Custody | The Irish Prison Service should further intensify its efforts to physically prevent contraband from entering prisons and to detect its presence once on the premises, including through physical and technological means. In this regard, the OIP welcomes the recent installation of new and more effective anti -drone netting on certain exercise yards at Mountjoy Prison, and at other prisons in Ireland. | Accepted | The Irish Prison Service continues to advance a series of goals under the Drugs Strategy 2023 -2026 to deter, detect and reduce the prevalence and harm of substances of abuse in the prison environment. | Operations | Ongoing | |||||||||||||||||
| 18/02/2026 | 18/07/2024 | Mountjoy | Security | Narcotics Detection | 2024Q4 | Death in Custody | The Irish Prison Service should continue to engage with other relevant stakeholders, especially with An Garda Síochána, to further develop a multi-agency strategy to counter contraband entering a prison. This strategy should examine the use of technology, architectural disruptions, as well as how to prevent exploitation and coercion being used as a means to traffic drugs and other contraband into a prison | Accepted - Already in Place | The Irish Prison Service and An Garda Síochána work in close partnership to prevent contraband entering prisons, supported by an evolving Memorandum of Understanding that adapts as new threats emerge. | Operations | Ongoing | |||||||||||||||||
| Date of Publication | Facility | Primary Keyword | Secondary Keyword |
Date of Publication:
Date of Death:
Facility:
Primary Keyword:
Secondary Keyword:
Recommendation ID:
Investigation Type:
Recommendation:
IPS Response:
Date of IPS Action Plan:
IPS Action Plan:
IPS Recommendation Owner:
Timeline:
2025 Assessment Date:
2025 Assessment Type / Status:
2025 Status Update Information:
Q2 2024 Assessment Date:
Q2 2024 Assessment Type / Status:
Q2 2024 Status Update Information:
Q1 / Q2 2023 Assessment Date:
Q1 / Q2 2023 Assessment Type / Status:
Q1 / Q2 2023 Status Update Information:
Q2 2022 Assessment Date:
Q2 2022 Assessment Type / Status:
Q2 2022 Status Update Information:
2020 Assessment Date:
2020 Assessment Type / Status:
2020 Status Update Information:
Recommendation & Status Update: