Investigations Recommendation Monitoring

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Date of Death	Date of Publication	Facility	Primary Keyword	Secondary Keyword	Investigation Type	Recommendation ID	Recommendation	IPS Response	Date of IPS Action Plan	IPS Action Plan	IPS Recommendation Owner	Timeline	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
05/01/2023	24/02/2025	Mountjoy Prison	Healthcare		Death in Custody	2023A	In all cases where a prisoner is returned to prison from hospital with a discharge letter containing a decision that they should not be resuscitated, prison health care staff should take active steps to ensure that this decision reflects the free and informed consent of the person concerned and this should be fully documented in the PHMS.	Partially Accepted	10/12/2024	In line with best medical practice, the instruction of a DNR (do not resuscitate) from a hospital is not valid outside of that setting. The Care and Rehabilitation Directorate will develop a standard form to capture DNR information which can then be uploaded onto the Prisoner Healthcare Management System	Care & Rehabilitation Directorate	Q1 2025	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
08/01/2023	29/07/2025	Wheatfield Prison	Next of Kin		Death in Custody	2023B1	The unexpected death of a son and a sibling is a painful experience in any circumstances, all the more so if the deceased and some of his siblings are imprisoned at the time. The Inspectorate has not been made aware of any individualised security concerns that required Mr B’s family members to be prohibited from physically comforting his incarcerated siblings, whether in Wheatfield Prison and/or at the funeral home. The Inspectorate acknowledges the efforts that were made by prison staff to be compassionate to Mr B’s family; however, it recommends that the IPS review its current policy in this area.	Not Accepted	27/06/2025	Management at Wheatfield Prison have confirmed that the family of Mr. B were not prohibited from physically comforting his incarcerated siblings.The Irish Prison Service assesses its capacity to make compassionate arrangements for prisoners and their families on a case by case basis, based on operational and security constraints.	Operations Directorate	Closed	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
12/01/2023	30/10/2025	Limerick Prison	Safety		Death in Custody	2023C1	If it is deemed necessary to isolate a person from the general prison population, because of a suspicion that that they have internally concealed 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 separation 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 . This recommendation was also made in the OIP’s report on the death in custody of Mr. I 2020 and partly accepted by the IPS	Partially accepted		The SOP for Close Supervision Cells outlines that a determination on the requirement for medical special observations in accordance with Prison Rule 102 will be made by the member of the Prison Healthcare Team who assesses the prisoner. Otherwise, the prisoner will remain on Rule 64 security monitoring with clinical review at intervals determined by the Prison Healthcare Team	Care & Rehabilitation / Operations	Complete	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
12/01/2023	30/10/2025	Limerick Prison	Policy		Death in Custody	2023C2	There is no systematic justification or rationale for the routine placement in refractory clothing of prisoners accommodated in a CSC cell. The Inspectorate recommends that this practice is brought to an end immediately. This Inspectorate recommendation is fully consistent with the views of the Council of Europe’s European Committee for the Prevention of Torture and Inhuman or Degrading Treatment (CPT) on this subject.	Not Accepted		Prisoners are placed in safety clothing in line with the requirements of the CSC SOP. Decisions on the use of safety clothing are made by both Prison Healthcare and the Prison Governor.	Care & Rehabilitation / Operations	Closed	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
12/01/2023	30/10/2025	Limerick Prison	Healthcare		Death in Custody	2023C3	In order to enhance the effectiveness of the healthcare 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. Kicking the bottom of a cell door is not a reliable method to verify signs of life. This recommendation was also made in the OIP’s report on the death in custody of Mr. I 2020 and accepted by the IPS.	Accepted - Already in Place		A multi-disciplinary working group was established in 2024 to examine to possibilty of implementing signs of life technology. Two prisons, namely Cloverhill and Limerick, have been identified as sites for a potential pilot project. Market research is currently underway to identify a product which can provide minimally invasive monitoring of prisoner life signs.	Care and Rehabilitation Directorat	Ongoing	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
12/01/2023	30/10/2025	Limerick Prison	Policy	Healthcare	Death in Custody	2023C4	The Irish Prison Service should introduce a healthcare focused policy to respond to the threats and safety risks posed by the internal concealment of drugs and other items of contraband. This policy should clarify the roles and responsibilities of management, prison officers, and healthcare staff. This new policy should provide for a central role for healthcare professionals in decision making regarding the supervision and care of a person where there is a suspicion of internal concealment of drugs and other items of contraband. All such decisions should include a recorded risk assessment . This recommendation was made in OIP’s report on the death in custody of Mr. I 2020 and accepted by the IPS.	Accepted - Already in Place		Procedures for the care and management of prisoners suspected of internally concealing any prohibited article or substance and associated healthcare interventions are included in the SOP for Close Supervision Cells. It should be noted that the final decision on supervision is a statutory power reserved by the Governor of the prison.	Care & Rehabilitation / Operations	Complete	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
12/01/2023	30/10/2025	Limerick Prison	Policy & Procedure	Healthcare	Death in Custody	2023C5	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. If the analysis is conducted by, or on behalf of, An Garda Síochána, clear channels of communication should be put in place to ensure that the results are quickly made known to prison management and healthcare staff.	Not Accepted		The Irish Prison Service will bring this recommendation to the next high level meeting with An Garda Síochána for consideration. It should be noted that in the event of an overdose, a facility is in place to allow for rapid testing of substances when it is believed there is a risk to life	Operations Directorate	Ongoing	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
12/01/2023	30/10/2025	Limerick Prison	Safety		Death in Custody	2023C6	The Irish Prison Service should intensify its efforts to physically prevent contraband from entering prisons and to detect its presence once on the premises, including through technological means. This recommendation was also made in the OIP’s report on the death in custody of Mr. I 2020 and accepted by the IPS. The IPS advised that they had established a sub-group to examine remote monitoring of vital signs technology. The group has met with European colleagues and further discussions are planned.	Accepted - Already in Place		See recommendation no. 3 above. The Irish Prison Service published a new Drug Strategy in 2023 with a renewed focus to address substance abuse in prisons. The Strategy identifies 3 essential areas of focus: Inform & Educate, Detect & Reduce, Support & Treat. Each heading confirms a set of practical goals to mitigate against the harmful effects of drugs in prisons. The Irish Prison Service Operational Support Group (OSG) are engaging with Comreg, IIAA and a number of companies regarding Drone incursions. Discussions have also taken place with European colleagues on other forms of technology to target contraband, and OSG continue to lead in this area for IPS. In addition, an MOU has been agreed between the Irish Prison Service and An Garda Síochána. As a result, there are ongoing and successful joint operations between IPS and An Garda Síochána to counter contraband entering a prison	Operations	Complete	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
12/01/2023	30/10/2025	Limerick Prison	Safety		Death in Custody	2023C7	The Irish Prison Service should engage with other relevant stakeholders to 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 . This recommendation was also made in the OIP’s report on the death in custody of Mr. I 2020 and accepted by the IPS.	Accepted - Already in Place		See recommendations no. 3 and 6 above.	Operations	Complete	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
12/01/2023	30/10/2025	Limerick Prison	Record Keeping		Death in Custody	2023C8	The Irish Prison Service should ensure that staff understand the importance of accurate records and the consequences of creating an inaccurate record/report of their duty. Regular audits should be carried out by line management to ensure compliance. A Similar recommendations have been made in the past in OIP’s reports on the deaths in custody of Messrs A 2012, H 2014, I 2018 and G 2021. As regards, more specifically, the recording of special observations of prisoners, the Inspectorate recommends that the relevant record books be amended to require prison officers to record the actual time at which they carry out each such observation.	Accepted		Staff who are found to falsify records are sanctioned in line with the Code of Discipline. One of the pillars of the Irish Prison Service's Strategic Plan 2023-2027 is to develop and enhance Digital Platforms within the Service. The digitisation of prison journals is a priority project under this pillar.	Corporate Services	Ongoing	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
26/01/2023	29/07/2025	Castlerea Prison	Record Keeping		Death In Custody	2023D1	All IPS records involving deaths in custody should be dated and signed. All timings of significant matters such as cell entries and arrival of emergency services should provide exact times section 9.15.	Accepted	27/06/2025	Governors will be reminded of their obligations in this regard at the July 2025 meeting of the Prisons' Leadership Team.	Operations Directorate	45839	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
26/01/2023	29/07/2025	Castlerea Prison	Record Keeping		Death In Custody	2023D2	It is crucially important that any contraband seized in the immediate aftermath of a death in prison custody should be swiftly analysed and the results of that analysis made available in a timely fashion to the management and the health care team in the prison concerned. This information can greatly assist in reducing the risk of future deaths. The Inspectorate invites the IPS to review its existing procedures in this area.	Not Accepted	27/06/2025	This recommendation will be considered when developing the revised template for Hot and Cold CIRMs following the finalisation of a new Death in Custody Policy.	Corporate Services Directorate	Q3 2025	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
26/01/2023	29/07/2025	Castlerea Prison	Contraband		Death in Custody	2023D3	The record of Hot and Cold CIRM should show who was invited to attend; reasons for non- attendance; and anything significant that nonattendees contributed to the proceedings e.g. in writing or by phone, section 12.1.	Accepted	27/06/2025	Contraband seized in the aftermath of a death in custody is evidence of An Garda Síochána, and analysis of this evidence is outside the control of the Irish Prison Service.The Irish Prison Service will bring this recommendation to the next high level meeting with An Garda Síochána for consideration.	Operations Directorate	Ongoing	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
26/01/2023	29/07/2025	Castlerea Prison	Policy		Death In Custody	2023D4	A Cold CIRM should be conducted within 14 days of the incident to provide further opportunity for everyone involved, including prisoners where relevant. The purpose should be to identify learning, support everyone involved and assess progress in relation to actions that were identified at the hot debrief, section 12.5.	Accepted - Already in Place	27/06/2025	The Irish Prison Service commenced a review of all Death in Custody related policies and SOPs in Q2 2024. As part of this, a revised interim process for reviewing deaths in custody was put in place, which advises that a Cold debrief review meeting will be conducted within 14 days of an incident where required and insofar as is operationally feasible.	Corporate Services Directorate	Ongoing	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
17/07/2023	09/10/2025	Midlands Prison	Safety		Death in Custody	2023L1	The Chief Inspector of Prisons has previously raised an Immediate Action Notification (IAN) regarding the cell call system in Cork Prison and identified the significant risks associated when a cell call notification is not responded to in a timely manner. This has also been specifically highlighted in the report on the death in custody of Mr. G 2021. The OIP reiterates that it is a core duty of Prison Officers to respond swiftly to cell call notifications. It recommends that the IPS draw up a national Standard Operating Procedure regarding cell call notifications, including a national standard in relation to cell call response times. The IPS should also devise a system for monitoring compliance and regular testing of all associated equipment across the entire prison estate.	Partially Accepted	27/06/2025	The Irish Prison Service is currently exploring cell call system models as part of a project to introduce an emergency call system. This recommendation will be considered as part of this process.	Operations Directorate	Ongoing	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
17/07/2023	09/10/2025	Midlands Prison	Policy & Procedure	Healthcare	Death in Custody	2023L2	It is recommended that the IPS develop and implement a national service-wide Suicide Prevention Policy and Strategy.	Partially Accepted	27/06/2025	The Irish Prison Service approach suicide and self harm from a reduction and risk management perspective, as opposed to prevention. The development of a Suicide Reduction Protocol will be progressed following the finalisation of the Irish Prison Service's new Death in Custody Policy and related SOPs.	Care and Rehabilitation Directorate	Ongoing	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
17/07/2023	09/10/2025	Midlands Prison	Policy & Procedure		Death in Custody	2023L3	As recommended at the CIRM, a SOP on safely removing incapacitated persons from cells with limited space should be developed.	Not Accepted	27/06/2025	Safely removing incapacitated persons from cells is covered in Basic Life Support refresher training which the Irish Prison Service nursing staff must attend bi-annually.As a standard part of this training, the casualty must be moved to an area where life saving interventions can be carried out safely and appropriately. It is hoped that, should a prisoner be required to be moved onto a landing for life saving interventions, that screens can be erected to shield them from view of other prisoners, thus preserving dignity. However, in emergency, time-critical situations, this is not always possible.	Care and Rehabilitation Directorate	Closed	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
17/07/2023	09/10/2025	Midlands Prison	Safety		Death in Custody	2023L4	It is recommended that Prison Officers be reminded of their obligation under Prison Rule 87(1)(b) which requires them to examine equipment in their area of responsibility and report any defects which could compromise good order, safe or secure custody or health and safety. This regular check should include verifying that the Hoffman knife safety box is accessible. A similar recommendation was made by the Inspectorate and accepted by the IPS in the death in custody report in relation to the death of Mr. G 2021	Accepted	27/06/2025	All Hoffman knife safety boxes were checked after the death of Mr. L, finding no reportable defects.This recommendation will be communicated to all Governors at the July 2025 meeting of the Prisons' Leadership Team.	Operations Directorate	Jul-25	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
17/07/2023	09/10/2025	Midlands Prison	Policy & Procedure		Death in Custody	2023L5	It is recommended that an inventory should be compiled by prison staff of any item(s) taken into the possession of An Garda Síochána. This formed part of a recommendation in the report on the death in custody of Mr. C 2022, which has been accepted by the IPS.	Accepted	27/06/2025	The IPS and AGS have established a number of working groups to examine ways to improve co-operation. One of the sub-groups is examining ways of achieving and maintaining the highest standards and best practice in the preservation, secure continuity, storage and record keeping of evidence. This recommendation has been submitted to this group for examination and full consideration.	Operations Directorate	Ongoing	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
	Date of Publication	Facility	Primary Keyword	Secondary Keyword