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| 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 |
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| 13/06/2019 | 06/05/2017 | Limerick Prison | 2017G1 | Death in Custody | Special Observations ensure that the required 15 minute checks by staff are complied with. | Accepted | 11/04/2019 | Introduction of measures to strengthen compliance 1 The modification of prison landing lighting to ensure visibility of staff conducting checks on CCTV (completed) 2 The amendment of our CCTV policy to provide prison management with the ability to review all night duty CCTV footage to satisfy themselves that full compliance with night guard duty is taking place on a consistent basis. 3 The introduction of • A new Monitoring of Prisoners Policy; • A new Healthcare Special Observations Policy • A Revised Close Supervision Cell Procedure • A Revised Safety Observation procedure; and • A new Monitoring of Prisoners during Night Guard Duty Protocol. 4 In circumstances where full compliance has not been possible the reasons for this will be required to be clearly set out in writing and verified by prison management with reference to the appropriate CCTV footage. 5 Standardisation of frequency and recording of unannounced night time visits by governors | Senior management within IPS HQ and Prison Governors | End February 2019 | Q2 2024 | IPS - Complete | No further action required. | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||||
| 13/06/2019 | 06/05/2017 | Limerick Prison | Prisoner Checks | 2017G2 | Death in Custody | Special Observations Failure by officers to carry out essential duties should be subject to the Disciplinary (Code for Officers) Rules. | Accepted | 11/04/2019 | IPS to implement guidelines on disciplinary sanctions for Special Ob’s policy breaches | Director, Human Resources | Q2 2019 | Q2 2024 | IPS - Complete | Possible sanctions detailed in IPS prisoner monitoring portal on PRISM. | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 13/06/2019 | 06/05/2017 | Limerick Prison | Record-Keeping | Property | 2017G3 | Death in Custody | All property in the possession of a prisoner who is committed to prison should be fully recorded and a detailed description entered in the prison records. | Accepted | 11/04/2019 | IPS will develop a Policy and SOP for personal items – | Operations Directorate | Q2 2019 | Q2 2024 | IPS - Complete | All property in the possession of a prisoner who is committed to prison continues to be recorded on committal and entered on the Prisoner Information Management System. | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 13/06/2019 | 06/05/2017 | Limerick Prison | Policies and Procedures | Implementation | 2017G4 | Death in Custody | A centralised Policy and Standard Operating Procedures should be developed to provide clarity in relation to the return of personal items following a death in custody. | Accepted | 11/04/2019 | IPS will develop a Policy and SOP for personal items – | Operations Directorate | Q2 2019 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | There is a review of DIC protocols ongoing which will ensure the implementation of this recommendation. | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 13/06/2019 | 06/05/2017 | Limerick Prison | Family Contact | Visits | 2017G5 | Death in Custody | Irish Prison Service should review its visitor booking system to ensure that visitors of unconvicted prisoners are facilitated with visits in accordance with Prison Rules. | Accepted | 11/04/2019 | Letter to issue to all Governors to reinforce their obligations in this regard | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 13/06/2019 | 06/05/2017 | Limerick Prison | Post-Incident Response | 2017G6 | Death in Custody | All CCTV must be saved as soon as possible following a serious incident and/or death in custody and it should be ‘locked-down/ secured’ electronically to avoid deletion. | Accepted | 11/04/2019 | Introduction of new platform for storage of CCTV | ICT | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 13/06/2019 | 06/05/2017 | Limerick Prison | Healthcare | Committal | 2017G7 | Death in Custody | A centralised Policy and Standard Operating Procedures should be developed to ensure the Nurse in-change is notified immediately when a new committal has in his/her possession medication and/or medical related material. | Accepted | 11/04/2019 | The IPS confirms that it has a current Healthcare Standard Operating Procedure which governs the Committal process. The Irish Prison Service is committed to a review of its current Standard Operating Procedure. | Care and Rehabilitation Directorate | Q2 2019 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | A resource has been assigned to the Healthcare Team to update all policies and SOP's. This work is ongoing but will conclude in Q1 2024. This work will be directly applicable to Limerick Prison. | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 13/06/2019 | 06/05/2017 | Limerick Prison | Healthcare | 2017G8 | Death in Custody | No medical items should be places in an area to which Nurses do not have 24 hour access. | Accepted | 11/04/2019 | The IPS confirms that it has a current Healthcare Standard Operating Procedure which governs the Committal process. The Irish Prison Service is committed to a review of its current Standard Operating Procedure. | Care and Rehabilitation Directorate | Q2 2019 | Q2 2024 | IPS - Complete | Medical items in the surgery and pharmacy are accessible to nursing staff. | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 13/06/2019 | 06/05/2017 | Limerick Prison | Post-Incident Response | 2017G9 | Death in Custody | To ensure full and accurate recall on the sequence of events a detailed operational report should be obtained from all staff who had a duty in the supervision of the prisoner and/ or a role in a critical incident such as a death in custody, before they report off duty on the date of the incident. | Accepted | 11/04/2019 | Letter to issue to all Governors to reinforce their obligations in this regard | Operations Directorate | End January 2019 | Q2 2024 | IPS - Complete | Recommendation implemented. | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 08/01/2020 | 10/01/2018 | Mountjoy Men's Prison | Prisoner Checks | 2018A1 | Death in Custody | Officers when unlocking prisoners after periods of lock-back should verbally communicate with the prisoner and ensure they receive a verbal response to verify that s/he is well and not in need of medical attention. | Accepted | 03/10/2019 | To be presented to the SPG on 18/19 September for discussion about practicality of implementation. | Operations Directorate | 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 | 31/12/2020 | IPS - Complete | NA | ||
| 08/01/2020 | 10/01/2018 | Mountjoy Men's Prison | Record-Keeping | 2018A2 | Death in Custody | The checking of prisoners in their cells should be conducted in accordance with the Irish Prison Service Standard Operating Procedure by the Officer assigned to the division/landing or by their approved relief officer. If an officer is required to respond to an emergency and in so doing is unable to complete required checks, an entry should be made in the appropriate Journal(s) (Night Guard Journal, Dinner Guard Journal etc.) by the officer concerned and countersigned by the supervising officer. | Accepted | 03/10/2019 | Introduction of measures to strengthen compliance: 1. The modification of prison landing lighting to ensure visibility of staff conducting checks on CCTV 2. The amendment of our CCTV policy to provide prison management with theability to review all night duty CCTV footage to satisfy themselves that full compliance with night guard duty is taking place on a consistent basis. 3. The introduction of • A new Monitoring of Prisoners Policy; • A new Healthcare Special Observations Policy • A Revised Close Supervision Cell Procedure • A Revised Safety Observation procedure; and • A new Monitoring of Prisoners during Night Guard Duty Protocol. 4. In circumstances where full compliance has not been possible the reasons for this will be required to be clearly set out in writing and verified by prison management with reference to the appropriate CCTV footage. | Senior management within IPS HQ and Prison Governors | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 08/01/2020 | 10/01/2018 | Mountjoy Men's Prison | Prisoner Checks | 2018A3 | Death in Custody | Where there is evidence to suggest that an officer(s) has/have failed to carry out his/her duties in relation to checking of prisoners in their cells appropriate disciplinary action should be taken. | Accepted | 03/10/2019 | IPS to implement guidelines on disciplinary sanctions for Special Observation policy breaches. Responsibilities and obligations of staff and consequences for failure to carry out duties without reasonable cause addressed by the Director General through written correspondence to all staff. Guidelines for Disciplinary sanctions to be formally published by 5th July, 2019. | Director Of Human Resources | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 08/01/2020 | 10/01/2018 | Mountjoy Men's Prison | Handover | Operational | 2018A4 | Death in Custody | All hand-over of duties should be recorded in the Night Journal by the Night Guard and signed off at the end of the tour of duty by the Supervising Officer / Officer-incharge. | Accepted | 03/10/2019 | IPS to implement guidelines on disciplinary sanctions for Special Observation policy breaches. Responsibilities and obligations of staff and consequences for failure to carry out duties without reasonable cause addressed by the Director General through written correspondence to all staff. Guidelines for Disciplinary sanctions to be formally published by 5th July, 2019. | Director Of Human Resources | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 21/10/2021 | 19/03/2018 | Cork Prison | Policies and Procedures | Implementation | 2018F1 | Temporary Release | The Irish Prison Service should prioritise the development and implementation of a Community Return/Support Scheme Policy and Standard Operating Procedure(s) for dissemination to all Irish Prison Service personnel. | Accepted | 19/02/2021 | This matter was discussed at the Irish Prison Service/Probation Service Oversight group on 16th September. It has been agreed that in light of the recent amendment to eligibility criteria for the Community Return Scheme and taking into account this recommendation, all current procedures will be reviewed and a joint protocol and overarching policy will be developed in the next 3 months. | Senior Management IPS/Probation Service | Delayed due to Covid 19. Policy to be finalised by end of April 2021 | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | The Protocol was completed and signed by the Director of Probation and the Director General of the Irish Prison Service in 2021. | NA | NA | NA | ||||
| 21/10/2021 | 19/03/2018 | Cork Prison | Policies and Procedures | Implementation | 2018F2 | Temporary Release | A Standard Operating Procedure (SOP) for notification in writing to a Garda Station to which a prisoner granted RTR is to report should be developed and implemented in each prison. The SOP should, at a minimum, clearly identify the post (at a senior level) to which the Governor delegated the responsibility, details regarding the prisoner that has been granted RTR and also the conditions attaching to his/her release. | Not accepted | 19/02/2021 | Recommendations 4.2 and 4.3 both reference the process of providing a hard copy of the temporary release form to An Garda Siochana is set out in circular OPS/15/2010, however this procedure was succeeded by circular OPS/03/2011 and then by the “Consolidated Guidelines for prisoners released on Temporary Release” which issued in 2012. This updated policy allows for an electronic copy of the terms and conditions for temporary releases to be send to An Garda Síochána. The prisoner themselves have two hard copies of their TR form which they present to the assigned Garda station. As such the Prison Service are not in a position accept these recommendations. | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 21/10/2021 | 19/03/2018 | Cork Prison | Policies and Procedures | Implementation | 2018F3 | Temporary Release | The Governor of the prison should put in place a review mechanism in relation to recommendation 4.2 so that he/she can satisfy him/herself that the SOP is being implemented. | Not accepted | 19/02/2021 | Recommendations 4.2 and 4.3 both reference the process of providing a hard copy of the temporary release form to An Garda Siochana is set out in circular OPS/15/2010, however this procedure was succeeded by circular OPS/03/2011 and then by the “Consolidated Guidelines for prisoners released on Temporary Release” which issued in 2012. This updated policy allows for an electronic copy of the terms and conditions for temporary releases to be send to An Garda Síochána. The prisoner themselves have two hard copies of their TR form which they present to the assigned Garda station. As such the Prison Service are not in a position accept these recommendations. | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 21/10/2021 | 19/03/2018 | Cork Prison | Policies and Procedures | Implementation | 2018F4 | Temporary Release | The Irish Prison Service should consult and agree a written Protocol with An Garda Síochána to ensure that any breach of Reviewable Temporary Release coming to the attention of An Garda Síochána is promptly reported in writing to Irish Prison Service HQ. | Accepted | 19/02/2021 | This recommendation will be addressed through a joint protocol and policy with An Garda Siochana. | Senior Management IPS/An Garda Siochana | Time frame will be advised following discussions with An Garda Siochana | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Relevant stakeholders across the IPS continue to engage with An Garda Síochána to improve information sharing at points of committal and release and to confirm these arrangements in the form of agreed protocols. | 01/06/2023 | IPS - Ongoing | The Irish Prison Service and An Garda Siochana met in late April to discuss this issue and others. A review of the shared UAL Protocol has commenced, this review will take account of changes to the AGS operating model and identify up-to-date Garda Liaison Officers for each prison. As part of this review, consideration will be given to establishing a new centralised reporting email structures between the two organisations, while the CJOH (Criminal Justice Information Hub) solution is forthcoming. | 01/09/2022 | IPS - Ongoing | The Irish Prison Service are engaging with AGS on the development of the protocol as recommended. The matter was discussed further at a meeting between the IPS and AGS in July. Implementation of this action will require the agreement of AGS. ------- Q4 2022 | NA | NA | NA | |
| 21/10/2021 | 19/03/2018 | Cork Prison | Temporary Release | Community support | 2018F5 | Temporary Release | The first meeting of a prisoner with the Probation Service and/or Community Project to which s/he is referred should be on the day of release or on the following working day. An early meeting would ensure that a prisoner released on Reviewable Temporary Release would have the necessary ‘community based supports’ in place immediately following his /her temporary release. | Accepted | 19/02/2021 | This recommendation will be considered by Probation Service during the development of the Joint Protocol referenced in recommendation 4.1 above. | Senior Management IPS/Probation Service | Delayed due to Covid 19. Policy to be finalised by end of April 2021 | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | The Protocol was completed and signed by the Director of Probation and the Director General of the Irish Prison Service in 2021. | NA | NA | NA | ||||
| 21/10/2021 | 19/03/2018 | Cork Prison | Next-of-Kin | Contact | 2018F6 | Temporary Release | As the recording of next of kin contact details is a statutory requirement under Rule 4(e)(ii), (iii) of the Prison Rules 2007–2017, the Irish Prison Service should make the entry of such information a mandatory field for completion on every occasion a person is committed to prison. The importance of providing details regarding a next of kin and the obligationsattaching to a next-of-kin should be clearly explained to a prisoner on committal. The IPS should also consider and implement a process whereby up to date details of next of kin of prisoners serving long sentences are available on the Prisoner Information Management System (PIMS). | Accepted | 19/02/2021 | Next of Kin details, where applicable, are recorded for all prisoners as part of the Governor’s Committal interview. This facility was developed into the Prisoner Information Management System as part of the Risk Assessment release in 2018. Previously Operations Directorate have requested that Governors update the Next of Kin field on a regular basis and have made an IT report available to facilitate this. Management in the Operations Directorate reissued Operations Circular OPS/6/2016 - Next of Kin to all Governors and requested that Class Officer speak to each prisoner to verify/amend/add that of kin details on PIMS. For clarification purposes - There are no implications of being nominated as “next-of-kin” as there is no legal definition within Irish Law for a next of kin. | Director of Operations | 12th December 2019 Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 29/07/2020 | 12/04/2018 | Mountjoy Men's Prison | Post-Incident Response | 2018H1 | Death in Custody | The IPS should ensure that minutes of important meetings, such as Critical Incident Reviews, should identify significant facts such as dates, times, roles and responsibilities as well personnel who did not attend, with explanations. The recommendations should allocate responsibility and timescales. | Accepted | 09/06/2020 | The Operations Directorate have a draft Critical Incident Management Booklet which is currently being developed. This booklet will address the recommendation of the Inspector. | Operations Directorate | End June 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | |||||
| 29/07/2020 | 12/04/2018 | Mountjoy Men's Prison | Post-Incident Response | Debriefing | 2018H2 | Death in Custody | A ‘hot debrief’ following a critical incident is held in prisons on a custom and practice basis. Therefore, the IPS should prioritise the development of a Critical Incident Policy to ensure a consistency of approach in all prisons. The policy should include (and not limited to) debriefings post critical incident. In addition to a ‘hot debrief’ (on the day or night of the incident as applicable) A ‘hot debrief’ following a critical incident is held in prisons on a custom and practice basis. Therefore, the IPS should prioritise the development of a Critical Incident Policy to ensure a consistency of approach in all prisons. The policy should include (and not limited to) debriefings post critical incident. In addition to a ‘hot debrief’ (on the day or night of the incident as applicable) consideration should be given to the inclusion of a cold debrief 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. | Accepted | 09/06/2020 | The Operations Directorate have a draft Critical Incident Management Booklet which is currently being developed. This booklet will address the recommendation of the Inspector. | Operations Directorate | End June 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | ||||
| 29/07/2020 | 12/04/2018 | Mountjoy Men's Prison | Family Contact | Visits | 2018H3 | Death in Custody | The IPS should ensure that prisoners (sentenced or on remand) are facilitated to receive the visits that they are legally entitled to under the Prison Rules 2007-2017. | Accepted | 09/06/2020 | The Director of Operations has issued a reminder to all Governors that, in relation to visits, it is the statutory responsibility of Governors to ensure prisoners receive all they are entitled to under the Prison Rules. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 29/07/2020 | 12/04/2018 | Mountjoy Men's Prison | Accommodation | Accessibility | 2018H4 | Death in Custody | All prisons should have access to a wheelchair accessible cell. | Accepted | 09/06/2020 | The Irish Prison Service have wheelchair accessible cells in 9 of the 12 prisons. Where a prisoner requires access to those cells they are transferred to the most suitable prison location. As part of the next capital strategy, the Irish Prison Service will consider the possibility of providing wheelchair accessible cells in those locations which currently don’t have one. | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Record-Keeping | Accuracy | 2018I1 | Death in Custody | The IPS should instruct all staff that their written records and verbal evidence in respect of Deaths in Custody and other significant incidents must be fully detailed and specific in relation to all factual aspects of the event including timings and job roles. | Accepted | 11/06/2020 | This recommendation was addressed in the Death in Custody Standard Operating Procedure. SOP included with action plan, this SOP was last updated on 20/8/19. In addition, the Irish Prison Service will remind all staff of their obligations to record all incidents and of the importance of recording incidents promptly and accurately on both the paper and electronic systems. | Operations Corporate Services | Complete Q2 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | Also, information and good practice on report writing has been published on the intranet as a guide. | ||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Record-Keeping | Accuracy | 2018I2 | Death in Custody | The IPS should ensure that all its staff understand professional practice requires adequate recording. The principle “If it was not recorded, it was not done” may provide a useful basis for future training and assessment of practice in supervision and appraisals. | Accepted | 11/06/2020 | The Irish Prison Service has brought to the attention of all Chief Nurse Officers the need to adhere to this recommendation at a meeting on 06/03/20. | Care and Rehabilitation | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Healthcare | Medical advice | 2018I3 | Death in Custody | The IPS should satisfy itself about the competence of all staff involved in this failure to follow the doctor’s orders and take any action necessary to ensure there is no repeat in any prison establishment. | Accepted | 11/06/2020 | The SOP for Referral to A/E was recirculated to all nursing staff on 06/12/19 Informative sessions took place following the DIC as a learning exercise. Following this, an Email group was established for nursing staff to communicate referral to relevant disciplines. The “Referral to hospital form” was implemented as part of the policy and this is transmitted via email to the Detail office/Chiefs office. This email group system is to be replicated in all prisons. | Care and Rehabilitation Directorate | Complete Complete End June 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | ||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Healthcare | Referral | 2018I4 | Death in Custody | In circumstances where urgent hospital referrals are deferred, the IPS should immediately apply increased frequency of nursing / medical checks until the transfer takes place. | Accepted | 11/06/2020 | Nursing staff were advised on 06/12/19 that the SOP is to be adhered to and that any required checks or assessments are carried out until the prisoner is transferred to hospital. Communications have been improved between the Detail Office and Healthcare in relation to the expected timeframe for transfers which allows nursing staff to plan care. | Care and Rehabilitation Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | End of Life Care | Compassionate temporary release | 2018I5 | Death in Custody | The IPS should review the application of its Compassionate Temporary Release Policy to ensure that prisoners who are terminally ill are appropriately released on licence in order to avoid the indignity of dying in prison. | Part Accepted | 11/06/2020 | Decisions re Temporary Release are made on a case by case basis in accordance with the legislation and polices in place. The decision maker cannot be restricted to give medical options more significance over other factors i.e. security concerns when making a decision. When making a decision in relation to temporary release the factors to be considered are set out in law under the Criminal Justice Act 1960, as amended by the Criminal Justice (Temporary Release of Prisoners) Act, 2003. In addition, the Irish Prison Service operate a “Compassionate Temporary Release on grounds of health and health related humanitarian grounds Policy” which contains the criteria to be considered in such cases but which also states that “Consideration of the release of a prisoner will be subject to the provisions of section 2 of Criminal Justice Act 1960, as amended.” However, an agreement is now in place between Operations Directorate, the Care and Rehabilitation Directorate and the IPS Clinical Lead whereby any queries on a medical nature which Operations may have, will be referred to the Clinical Lead and they will guide the decision making process. | Care and Rehabilitation Directorate/ Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Next-of-Kin | 2018I6 | Death in Custody | The IPS Protocol for Chaplaincy and Next of Kin Notification dated 25/05/2017 at Section 2.3 makes provision for informing next of kin in cases of grave illness. The IPS should monitor implementation of the Protocol and take appropriate action if there is non-compliance. | Accepted | 11/06/2020 | The Chaplaincy group met on 5th September 2019, reviewed the policy and recommended some changes. These recommendations will be addressed by the newly appointed the Head Chaplain to ensure that the policy is fully implemented. | Care and Rehabilitation Directorate | Q2 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | The protocol is being implemented, but a Prison Chaplain may not always be available immediately when deaths occur out of hours. | |||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Post-Incident Response | 2018I7 | Death in Custody | The IPS should apply the following rationale for Critical Incident Reviews: “The purpose is to provide staff and any prisoners who were involved with an opportunity to share views in relation to how the situation was managed, and identify any additional support or learning that could have assisted.” Critical Incident Reviews should therefore be arranged to facilitate the attendance of those who were centrally involved, including prisoners, carers and staff from support agencies. | Accepted | 11/06/2020 | Operations are in the process of developing a Critical Incident Procedures Manual, which will cover, inter alia, Critical Incident Planning, Production of Critical Plans, post incident procedures and investigations and debriefing. | Operations Directorate | End June 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | |||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Post-Incident Response | 2018I8 | Death in Custody | Critical Incident Review minutes should reflect action points and responsibilities so that all relevant personnel understand what is required. This is especially true when key players did not attend the Review. | Accepted | 11/06/2020 | Operations are in the process of developing a Critical Incident Procedures Manual which will cover, inter alia, Critical Incident Planning, Production of Critical plans, post incident procedures and investigations and debriefing. | Operations Directorate | End June 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | |||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Healthcare | Referral | 2018I9 | Death in Custody | The IPS should ensure all referrals to outside hospital are prioritised when a doctor designates them as “Urgent”. | Accepted | 11/06/2020 | A reminder issued to prison operational staff and prison management staff on 06/12/19 re-emphasising the importance of prioritising Doctors referrals noted as “urgent”. An email group has been established to ensure that all relevant disciplines are aware of the transfer and the timeframe that is recommended. Once an email has issued there is a follow up phone call to the Chief’s Office and the Detail Office to relay the relevant information. This email group system will be replicated in all prisons. | Care and Rehabilitation Directorate | Complete Complete End June 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | ||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Post-Incident Response | Supports | 2018I10 | Death in Custody | The IPS should ensure that all staff are cared for after a critical incident, including those who are experienced and appear to cope well at the time. | Accepted | 11/06/2020 | The Irish Prison Service has committed in its Strategic Plan 2019 to 2022 to developing a Staff Wellbeing Strategy to raise awareness among staff of mental, emotional and physical health issues and to promote the positive physical and mental health of all employees. The Irish Prison Service aims to provide staff with the best possible supports, including a network of Staff Support Officers, the Employee Assistance Programme and access to a 24/7/365 confidential counselling service provided by Inspire Workplaces. The Irish Prison Service introduced the Critical Incident Stress Management (CISM) model of interventions for staff. CISM comprises vital, immediate support for staff in the aftermath of a serious or traumatic incident and a continuum of care which targets the response of individuals and groups of individuals to traumatic events rather than the incident itself. It aims to minimise the emotional impact of critical incidents on staff, increases the resistance and resilience of IPS staff to harmful stress and prevent harmful effects on staff by working and supporting IPS staff at the time of, and after, critical incidents. The CISM model has now become fully operational in all locations and efforts are continuing to increase the number of trained personnel. In Addition, the Continuous Professional Development programme of training delivered by the IPS College aims to provide staff with the competencies and personal resilience required to carry out their duties as safely as possible. The college also provides staff with psychological well-being training since January 2018. | Human Resources Directorate | On-going Complete | Q2 2024 | IPS - Complete | Recommendation implemented. | 01/06/2023 | IPS - Ongoing | To date the Human Resources Directorate has not been in a position to develop a staff well-being strategy due to resource constraints. A temporary part-time resource has recently been allocated to this project and it is intended to reconvene the Well Being Steering Group by the end of 2023, this group will advance the Well Being Programme for staff. The IPS have been engaging with Healthy Ireland during 2023 to discuss how to progress the implementation of the Healthy Ireland Programme. There are a number of support available to IPS staff including • Employee Assistance Officers who provide support to colleagues experiencing distress • Inspire Workplace provide independent, confidential counselling • The Inspire Support Hub was rolled out in June 2023. It is an online platform rolled out to all staff providing wellbeing information and toolkit, video library guided self-assessments with access to personalised recommendations. Another new feature of the enhanced Hub is a facility to arrange counselling sessions via a self-referral form. • The CISM (Critical incident stress management) model is fully operational in all locations. Efforts are continuing to increase the number of trained personnel and to heighten awareness of the potential of CISM in safeguarding the emotional and physical well-being of prison staff. • The Irish Prison Service have registered with the Pieta Amber Flag Initiative. This initiative aims at creating healthy and inclusive environments that support mental well-being for all employees. Fundraising events and Mental Health Awareness Days/Weeks have been organised across the estate since March 2023. The Pieta Amber Flag has been awarded to all 16 locations across the Prisons Estate in June 2023 | 01/09/2022 | IPS - Ongoing | The Irish Prison Service has rolled out Critical Incident Stress Management in all locations to ensure that all staff are adequately support following a serious incident. In addition, the Irish Prison Service has been engaged with the HSE with regard to the introduction of a Wellbeing Programme for Staff. The Introduction of same has been delayed by the Covid-19 pandemic. The introduction of a wellbeing programme is being prioritised for development and implementation in 2023. ---------- Q2 2023 | 31/12/2020 | IPS - Ongoing | NA | ||||
| 12/08/2020 | 14/06/2018 | Midlands Prison | Post-Incident Response | Debriefing | 2018I11 | Death in Custody | The IPS should consider the introduction of a ‘cold debrief’ within 14 days of a critical 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’. | Accepted | 11/06/2020 | Operations are in the process of developing a Critical Incident Procedures Manual which will cover, inter alia, Critical Incident Planning, Production of Critical plans, post incident procedures and investigations and debriefing. | Operations Directorate | End June 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Information | Share with OIP | 2018K1 | Death in Custody | For the purposes of Death in Custody investigations the IPS should provide the Inspector of Prisons with all documentation provided by AGS when a prisoner was transferred into IPS custody. | Accepted | 05/06/2020 | All staff were advised on 13 November 2019 of their statutory obligation to provide information to the IOP in accordance with Section 31(7) Prisons Act 2007. | Director of Care & Rehabilitation | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Record-Keeping | Prisoner movement | 2018K2 | Death in Custody | IPS records of requests for transfers between prisons should indicate in detail the reason for the request. When prisoners are being transferred in the interests of good order and discipline, targets should be set with them as an incentive towards improved conduct. | Accepted | 05/06/2020 | Prisons (and APs in Operations) have been requested to make clear the reason for the transfer which primarily tend to be for reasons of (i) accommodation (overcrowding) (ii) sentence management/progression (iii) security and good order (iv) other operational reasons (to facilitate a Court appearance, hospital appointment etc). Reminder issued to relevant staff 09/03/20. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Restricted Regime | 2018K3 | Death in Custody | The IPS should set a target to reduce the numbers of prisoners held in protection in Mountjoy Prison. This should commence with an analysis of application of Rule 63 and other forms of protection. | Part Accepted | 05/06/2020 | A reduction of the number of prisoners held under Rule 63 would necessitate an amendment to the Prison Rules and a removal of a prisoner’s entitlement to self-request protection. The Irish Prison Service as part of a Review of Rule 63 is currently actively considering this. The findings of this review will be made available to the Inspector. | Operations Directorate and Department of Justice and Equality | NA | NA | NA | NA | 15/05/2023 | IPS - Complete | Completed 2022 | NA | NA | NA | NA | NA | NA | |||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Restricted Regime | 2018K4 | Death in Custody | The IPS should improve the regime for protection prisoners and make every effort to safeguard their mental health by maximising opportunities for social interaction with other prisoners, staff and visitors. | Accepted | 05/06/2020 | Please see note for recommendation 3. This recommendation will be considered in the context of the review. All schools offer some education provision to prisoners on Rule 63. There are 13 Prison Education Centres, of which 9 provide education services to protection prisoners and 4 do not have protection prisoners (Shelton Abbey, Loughan House, Mountjoy West and Arbour Hill). In some cases there are school facilities available to prisoners in protection areas (e.g. A Block in Portlaoise, North School Wheatfield) and a timetable of classes is available. In other cases the main school or a secure section of the school is available to protection groups at restricted times, subject to the secure management of groups/factions – the main school is unavailable to other prisoners at these times (e.g. Mountjoy, Limerick, Cork). Teachers also provide study materials to students that they can study in their own cells. A Regime Management Planning process has been put in place by all prisons that aims to maximise the regime activities available to prisoners, including protection prisoners. | Care and Rehabilitation Directorate | NA | NA | NA | NA | 15/05/2023 | IPS - Complete | Completed 2022 | NA | NA | NA | NA | NA | NA | |||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Contraband | 2018K5 | Death in Custody | The IPS should conduct regular routine and unannounced cell searches for illicit material. The results should be made available to the Inspector of Prisons for the purposes of Death in Custody investigations. | Accepted | 05/06/2020 | Insofar as resources allow, targeted (cellspecific) and general area searches of prisons occur on a regular basis with the aim of retrieving contraband. OSG regularly provide Operations and the Statistics Unit with contraband seizure figures. These figures are now available on the Prison Service website. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | CCTV | Quality | 2018K6 | Death in Custody | In relation to CCTV - The IPS should urgently review its quality control processes for CCTV monitoring in Mountjoy and throughout the prisons estate; | Accepted | 05/06/2020 | The Irish Prison Service recently published its reviewed CCTV Surveillance Policy (copy attached) and these points are dealt with in paras 3.1.3, 3.1.7, 3.3.6 and 3.3.8 of that Policy. 3.1.3 - The Governor will at all times ensure the proper and responsible operation of the CCTV system under his/her control and ensure that all persons operating or monitoring the system are appropriately trained in the system’s use and understand the restrictions and legal obligations imposed upon them by the laws in this area. 3.1.7 - The CCTV Manager, nominated by the Governor in each prison, will have responsibility for ensuring the proper, efficient and orderly day-to-day operation of the CCTV system. 3.3.6 - Cameras must be properly maintained and serviced to ensure that clear images are recorded. 3.3.8 - A maintenance log/record shall be kept by the CCTV Manager. Further, all CCTV Managers underwent training for the new CCTV victor system (which is replacing the intellex system on a phased basis) provided by the Irish Prison Service College on their duties and obligations under the Revised Policy. | Operations Directorate/ Governors/IPSC | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | CCTV | Training | 2018K7 | Death in Custody | In relation to CCTV - It should satisfy itself that staff who monitor CCTV footage are trained and competent to fulfil all their duties and take any action necessary to remedy deficient practice. | Accepted | 05/06/2020 | The Irish Prison Service recently published its reviewed CCTV Surveillance Policy (copy attached) and these points are dealt with in paras 3.1.3, 3.1.7, 3.3.6 and 3.3.8 of that Policy. 3.1.3 - The Governor will at all times ensure the proper and responsible operation of the CCTV system under his/her control and ensure that all persons operating or monitoring the system are appropriately trained in the system’s use and understand the restrictions and legal obligations imposed upon them by the laws in this area. 3.1.7 - The CCTV Manager, nominated by the Governor in each prison, will have responsibility for ensuring the proper, efficient and orderly day-to-day operation of the CCTV system. 3.3.6 - Cameras must be properly maintained and serviced to ensure that clear images are recorded. 3.3.8 - A maintenance log/record shall be kept by the CCTV Manager. Further, all CCTV Managers underwent training for the new CCTV victor system (which is replacing the intellex system on a phased basis) provided by the Irish Prison Service College on their duties and obligations under the Revised Policy. | Operations Directorate/ Governors/IPSC | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | CCTV | Quality | 2018K8 | Death in Custody | The IPS should review its external contracts to ensure they are fit for purpose and delivering against all requirements. Those that impact upon safety and security should be prioritised. | Accepted | 05/06/2020 | The Building Services Division of the Finance and Estates directorate holds regular meetings with the service provider of the CCTV maintenance contract to address any non-performance/ issues / programming. In addition, ongoing investment in technology is due to take place to assist in the notification of faults via an early warning display for managers and users. | Estates Directorates | Ongoing | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | The IPS has deployed a new CCTV management system to monitor faults and give early warnings to the Prison control room if faults are on the system. The Service has also started a training program for CCTV managers on each site to manage the large amount of cameras under their control. | 31/12/2020 | IPS - Ongoing | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Post-Incident Response | Debriefing | 2018K9 | Death in Custody | A cold debrief 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. | Accepted | 05/06/2020 | Operations are in the process of developing a Critical Incident Procedures Manual which will cover, inter alia, Critical Incident Planning, Production of Critical plans, post incident procedures and investigations and debriefing. | Senior Management Operations | End June 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Post-Incident Response | Supports | 2018K10 | Death in Custody | The IPS should ensure all staff are cared for after a critical incident, including those who are experienced and appear to cope well at the time. | Accepted | 05/06/2020 | The Irish Prison Service has committed in its Strategic Plan 2019 to 2022 to developing a Staff Wellbeing Strategy to raise awareness among staff of mental, emotional and physical health issues and to promote the positive physical and mental health of all employees. The Irish Prison Service has introduced the Critical Incident Stress Management (CISM) model of interventions for staff. CISM comprises vital, immediate support for staff in the aftermath of a serious or traumatic incident and a continuum of care which targets the response of individuals and groups of individuals to traumatic events rather than the incident itself. It aims to minimise the emotional impact of critical incidents on staff, increases the resistance and resilience of Irish Prison Service staff to harmful stress and prevent harmful effects on staff by working and supporting IPS staff at the time of, and after, critical incidents. The CISM model has now become fully operational in all locations and efforts are continuing to increase the number of trained personnel. Also, the Continuous Professional Development programme of training being delivered by the Irish Prison Service College aims to provide staff with the competencies and personal resilience required to carry out their duties as safely as possible. It provides staff with psychological well-being training since January 2018. The Irish Prison Service aims to provide staff with the best possible supports, including a network of Staff Support Officers, the Employee Assistance Programme and access to a 24/7/365 confidential counselling service provided by Inspire Workplaces. | Human Resources Directorate | On-going Complete | Q2 2024 | IPS - Complete | Recommendation implemented. | 01/06/2023 | IPS - Ongoing | To date the Human Resources Directorate has not been in a position to develop a staff well-being strategy due to resource constraints. A temporary part-time resource has recently been allocated to this project and it is intended to reconvene the Well Being Steering Group by the end of 2023, this group will advance the Well Being Programme for staff. The IPS have been engaging with Healthy Ireland during 2023 to discuss how to progress the implementation of the Healthy Ireland Programme. There are a number of support available to IPS staff including • Employee Assistance Officers who provide support to colleagues experiencing distress • Inspire Workplace provide independent, confidential counselling • The Inspire Support Hub was rolled out in June 2023. It is an online platform rolled out to all staff providing wellbeing information and toolkit, video library guided self-assessments with access to personalised recommendations. Another new feature of the enhanced Hub is a facility to arrange counselling sessions via a self-referral form. • The CISM (Critical incident stress management) model is fully operational in all locations. Efforts are continuing to increase the number of trained personnel and to heighten awareness of the potential of CISM in safeguarding the emotional and physical well-being of prison staff. The Irish Prison Service have registered with the Pieta Amber Flag Initiative. This initiative aims at creating healthy and inclusive environments that support mental well-being for all employees. Fundraising events and Mental Health Awareness Days/Weeks have been organised across the estate since March 2023. The Pieta Amber Flag has been awarded to all 16 locations across the Prisons Estate in June 2023 | 01/09/2022 | IPS - Ongoing | The Irish Prison Service has rolled out Critical Incident Stress Management in all locations to ensure that all staff are adequately support following a serious incident. In addition, the Irish Prison Service has been engaged with the HSE with regard to the introduction of a Wellbeing Programme for Staff. The Introduction of same has been delayed by the Covid-19 pandemic. The introduction of a wellbeing programme is being prioritised for development and implementation in 2023. ---------- Q2 2023 | 31/12/2020 | IPS - Ongoing | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Information | Share with OIP | 2018K11 | Death in Custody | The IPS should prioritise Death in Custody investigations and adhere to the protocol that requires all relevant material to be provided to the Inspector of Prisons within seven days of the prisoner’s death. | Accepted | 05/06/2020 | This recommendation is addressed in the Death in Custody Standard Operating Procedure. SOP included with action plan, this SOP was last updated on 20/8/19. | Senior Management Operations | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 10/08/2020 | 25/06/2018 | Mountjoy Men's Prison | Record-Keeping | 2018K12 | Death in Custody | Internal IPS reviews into Deaths in Custody should have a clear format, structure and content. | Accepted | 05/06/2020 | This recommendation is addressed in the Death in Custody Standard Operating Procedure. SOP included with action plan, this SOP was last updated on 20/8/19. | Senior Management Operations | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 16/04/2021 | 19/07/2018 | Cork Prison | Accommodation | Bed | 2018L1 | Death in Custody | A person committed to prison should be accommodated in a bed unless otherwise contraindicated in exceptional circumstances. If a bed is available and it is decided not to avail of it, the decision and the associated reason(s) for the decision should be clearly documented. | Accepted | 22/04/2020 | Operations Directorate to issue a circular advising Governors to note on a prisoners file where a bed is available and it is decided not to use it. It must be noted that the Irish Prison Service has no control over the number of prisoners which may be committed to prison on a given day. Further, in circumstances where all of our closed prisons are currently operating at, close to, or above operational bed capacity, it is not possible to provide a bed and on occasions mattresses must be used. To assist in addressing overcrowding, new beds (bunks) have been introduced across the estate over the recent months. | Operations | Complete 11/03/2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 16/04/2021 | 19/07/2018 | Cork Prison | Special Observation | 2018L2 | Death in Custody | Consideration should be given to using a Special Observation Cell in circumstances where the IPS Protocol for the Emergency Use of Chlordiazepoxide is initiated. | Not accepted | 22/04/2020 | There is no clinical rationale for the placement of a person in an SOC if/ when they are in withdrawals or have been administered Chlordiazepoxide under protocol. Indeed the use of the SOC in such circumstances would be clinically inappropriate and contravene the SOC Policy and all clinical best practice. The criteria for SOC placement are clear, and are solely for the risk to self and/or others, and does not, nor should not, include commencement on protocol meds or undergoing alcohol withdrawals. | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 16/04/2021 | 19/07/2018 | Cork Prison | Handover | Nursing | 2018L3 | Death in Custody | Significant information relating to handover of nursing care, should be documented in writing in the relevant sections of PHMS and also communicated verbally ensuring appropriate exchange of relevant information at the handover of nursing shifts. | Accepted | 22/04/2020 | All PHMS users reminded of the available functionality on PHMS to support timely communication, record keeping and appropriate medication administration records. | Operational Nurse Manager/ PHMS Business Manager | Complete 05/03/2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 16/04/2021 | 19/07/2018 | Cork Prison | Healthcare | Record | 2018L4 | Death in Custody | Entry to records should be made contemporaneously. If for a particular reason this is not possible, the reason should be explicitly stated and the entry countersigned by the person’s line manager. | Part Accepted | 22/04/2020 | It is expected that all clinicians will enter contemporaneous notes. If a note cannot be entered in a timely manner, then it should be entered as soon as possible, with a clearly stated reason for the delayed entry. It is inappropriate that a manager would be expected to countersign an entry for a professionally qualified and accountable person. Individual professional accountability is one of the mainstays of a professionally qualified clinician irrespective of discipline. | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 16/04/2021 | 19/07/2018 | Cork Prison | Healthcare | Staffing | 2018L5 | Death in Custody | Chapter 18 and Appendix XIX of The IPS Clinical Drug Treatment & Policies Manual V 01 07 2012 requires updating to clearly address the issues identified at sections 6.6 and 6.7 of this report. The policies and procedures should take into consideration lone working nursing staff at night and provide appropriate guidance in such circumstances, including when transfer to hospital for emergency care is indicated. | Accepted | 22/04/2020 | Work is underway in reviewing the clinical demands and necessity for possible enhanced nursing at night time, however it is important to state that the principles of management of a presenting clinical scenario such as this would not differ from day duty to night duty or lone working to a full team being present. | IPS National Nurse Manager, Chief Pharmacist, and IPS Clinical Director | Subject to outcome of review and necessary resources being made available | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Healthcare have been assigned a resource to work on updating policies, procedures and SOP's and Clinical Drug Treatment and Policies Manual is part of this project and will be updated appropriately in due course. | 01/06/2023 | IPS - Ongoing | Advancing this recommendation is subject to outcome of the implementation process and necessary resources being made available. The Irish Prison Service will keep the Office of the Inspector of Prisons informed of developments in this area. | 01/09/2022 | IPS - Ongoing | The resourcing requirements for nursing including night time cover were considered by the consultants carrying out the Health Needs Assessment. The Report of the Health Needs Assessment and recommendations are being considered by the Irish Prison Service and it is proposed to develop an implementation plan. Implementation of recommendations will be subject to prioritisation and available resources. | NA | NA | NA | |
| 16/04/2021 | 19/07/2018 | Cork Prison | Healthcare | Medical assessment | 2018L6 | Death in Custody | The IPS Protocol for the Emergency Use of Chlordiazepoxide provides that “the patient must be seen by a doctor within 24 hrs”. This provision also requires review to incorporate earlier assessment/review by a registered medical practitioner. | Accepted | 22/04/2020 | The Irish Prison Service will review this as part of the Drugs & Therapeutics Committee work, for consideration and clarification to be provided to all clinicians. | IPS National Nurse Manager, Chief Pharmacist, and IPS Clinical Director | 6/18/2020 | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | The protocol for the Emergency Use of Chlordiazepoxide was updated in 2021 and is due for review in 2023 | NA | NA | NA | ||||
| 16/04/2021 | 19/07/2018 | Cork Prison | Healthcare | Policy review | 2018L7 | Death in Custody | The Irish Prison Service Epilepsy Management Protocol is silent in relation to situations where two or more seizures of less than 5 minutes duration occur within a specified period of time. It is recommended that the policy is reviewed to address this issue. | Accepted | 22/04/2020 | Draft revised SOP has been circulated for comment. This will be reviewed at the Drug and Therapeutics Committee. | IPS National Nurse Manager, Chief Pharmacist, and IPS Clinical Director | 6/18/2020 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | The Emergency Response to Prisoners having a Seizure Protocol has been drafted and distributed to the Drug and Therapuetic Committee for consideration. This Protocal will be finalised shortly. | 01/06/2023 | IPS - Ongoing | The Drugs and Therapeutics met on 20th June 2023 and this issue was discussed. A revised Protocol related to ‘Emergency Response to Prisoner having a Seizure’ has been circulated by the Senior Pharmacist and is awaiting final sign off from the D&T Committee | 01/09/2022 | IPS - Ongoing | The Epilepsy Management Protocol was updated in 2021, a further update was required in 2022, this is currently with the Drugs and Therapeutics Committee for their observations. | NA | NA | NA | |
| 16/04/2021 | 19/07/2018 | Cork Prison | Healthcare | Record | 2018L8 | Death in Custody | Handwritten notes of prisoner’s vital signs should be contemporaneously entered into the record in the area of the PHMS designated for this purpose. | Accepted | 22/04/2020 | Instruction issued 20/11/19 via the National CNO Group Meeting that all nursing staff must ensure that written records taken during their rounds must be entered into the respective prisoner notes on PHMS at the earliest opportunity. | IPS National Nurse Manager | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 08/01/2020 | 15/10/2018 | Cork Prison | Temporary Release | 2018N1 | Death in Custody | IPS should consider reviewing the procedures for notification to AGS of persons granted RTR and ensure that agreed procedures are implemented. | Accepted | 25/10/2019 | The IPS have arranged a meeting with An Garda Siochana for November 22nd and as part of this meeting we intend to discuss the recommendation in detail. | Senior Management IPS/An Garda Siochana | Ongoing The IPS are not in a position to provide a time frame for completion of this recommendation at this time. Time frame will be advised following discussions with An Garda Siochana | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | |||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Next-of-Kin | 2018O1 | Death in Custody | When it is known that death is imminent, the IPS should clarify with a prisoner’s Next-of-Kin that they accept that status and fully understand the implications. | Not accepted | 10/06/2020 | There are no implications of being nominated as “next-ofkin” as there is no legal definition within Irish Law for a next of kin. There is no obligation on a person designated as next of kin to pay funeral expenses. As a general rule, whomever arranges the funeral, usually covers the cost. I should highlight that in this case the next of kin did arrange the funeral however, the Irish Prison Service covered in full the cost relating to the funeral. | Operations Directorate | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | End of Life Care | Compassionate temporary release | 2018O2 | Death in Custody | Clarification in relation to Referral letters from Registered Medical Practitioners to the Operations Directorate requesting Compassionate Temporary Release for a prisoner on the grounds of health should be sought from the Registered Medical Practitioner who authored the letter, or, if unavailable, by another Registered Medical Practitioner following examination of the prisoner concerned. | Accepted | 10/06/2020 | An agreement in now in place between Operations Directorate, the Care and Rehabilitation Directorate and the Irish Prison Service Clinical Lead whereby any queries of a medical nature which Operations may have, will be referred to the Clinical Lead and they will guide the decision making process. | Operations/Care and Rehabilitation | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | End of Life Care | 2018O3 | Death in Custody | End of Life Care for prisoners is not a frequent occurrence. It is recommended that the decision-maker in each case should visit and speak directly with the prisoner concerned, relevant medical, nursing and other healthcare personnel providing care and treatment in the prison and also prison management and chaplaincy. | Not accepted | 10/06/2020 | It is the role of local prison management to speak and engage directly with the prisoner. All relevant information is made available to the decision maker in relation to an individual case. It is not considered a necessary or appropriate role for the decision maker to meet the prisoner in respect to whom they are required to make the decision. Such decisions are made in accordance with the relevant protocol and legislation. Irish Prison Service policy is that the identity of decision makers is not disclosed to any prisoner for security and operational reasons. | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Healthcare | Medical advice | 2018O4 | Death in Custody | In situations where the decision-maker is in receipt of conflicting healthcare advices the medical view should take precedence as s/he is the clinician with ultimate responsibility for the healthcare and treatment of the prisoner concerned. | Not accepted | 10/06/2020 | The Irish Prison Service do not believe that there were conflicting healthcare advices in this case. Both Dr A and National Nurse Manager A confirmed that the prisoner’s illness was terminal and that the prisoner would pass within 4 weeks. Irish Prison Service policies and procedures confirm that the prison doctor is the lead clinician in the primary care team. | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Record-Keeping | Prisoner movement | 2018O5 | Death in Custody | Prisoner information in relation to external and internal movements should be contemporaneously entered into the PIMS. | Accepted | 10/06/2020 | The Irish Prison Service will remind all prisons of their obligations to record all incidents and of the importance of recording incidents promptly and accurately on both the paper and electronic systems. | Corporate Services | September 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | ||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Communications | 2018O6 | Death in Custody | As the IPS operates on a 24 hour 365 day of the year basis, it should ensure that decisions required from senior management in IPS HQ are available in a timely manner and are addressed with an appropriate level of urgency. | Not accepted | 10/06/2020 | The working hours of the Irish Prison Service HQ administrative staff are set out in DPER Circular 11/2013 Title: “Revision of Working Hours and Flexible Working Arrangements for Civil Servants” and are remunerated accordingly. Prisons operate on a 24/7, 365 basis and prison staff are remunerated accordingly. Operations Directorate provide a 24/7 service for emergencies only, such as hospital transfers, death in custody, major disturbances etc. The Irish Prison Service is currently conducting a review of the out of hour’s on-call system and will inform the Inspector of the outcome of that review. It is intended to have this review complete by end May 2020. As any amendments may impact on the terms and conditions of employment of HQ staff the Irish Prison Service is not in a position to commit to accepting the recommendation at this stage. | NA | N/A (Please note the review of the out of hours call system which was originally due for completion by end May 2020 has been delayed due to Covid-19) | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Policies and Procedures | Implementation | 2018O7 | Death in Custody | The IPS should ensure that internal communication is at all times respectful and appropriate action taken when this standard is not reached. The development of a Code of Ethics for all IPS personnel (senior management and staff in HQ and prisons) should be expedited for completion and subsequent implementation at the earliest opportunity. | Accepted | 10/06/2020 | The new Code of Ethics will be circulated to all staff by 10 January 2020 with a notice from the Director General advising staff of the implementation of same. An accompanying awareness programme is currently being developed and will be delivered to all staff, commencing February 2020. | Corporate Services | February 2020 (Please note the new Code of Ethics which was originally due for completion by Feb 2020 has been delayed due to Covid19. But is expected to be complete by year end) | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | The Code of Ethics for the Irish Prison Service was published in December 2021. | 31/12/2020 | IPS - Ongoing | The Code of Ethics draft material was finalised in 2019 and is being reviewed for publication. A communications and implementation plan is being developed to support publication of the document. | ||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Communications | 2018O8 | Death in Custody | Requests for a meeting with a representative of the Minister in accordance with Rule 57 should be addressed in a timely manner. The recipient of the request should make immediate contact with the prison concerned to assess the urgency of the matter. | Part Accepted | 10/06/2020 | Rule 57 (2) states that “An officer of the Minister, designated by the Director General, shall, as soon as is practicable, visit the prisoner and hear any request or complaint which the prisoner may wish to make”. The Irish Prison Service is committed to operating in accordance with this Rule. However, this does not mean that immediate contact will be made in every case. The working hours of the Irish Prison Service HQ administrative staff are set out in DPER Circular 11/2013 Title: Revision of Working Hours and Flexible Working Arrangements for Civil Servants and are remunerated accordingly. Prisons operate on a 24/7, 365 basis and prison staff are remunerated accordingly. Operations Directorate provide a 24/7 service for emergencies only, such as hospital transfers, death in custody, major disturbances etc. In this instance, the request was received by email at 19.09 on the Friday evening of a Bank Holiday weekend. Unfortunately the prisoner passed away on the Tuesday after the Bank Holiday. | Operations | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Communications | 2018O9 | Death in Custody | The representative of the Minister that meets with a prisoner under Rule 57 should not be the original decision-maker in a decision that that prisoner may wish to discuss/raise with the representative. The representative should be of sufficient seniority to make appropriate recommendation for decision. | Not accepted | 10/06/2020 | Operations currently have an Assistant Principal Officer assigned to each prison as the designated official for rule 57 requests and as decision maker. It is not proposed to alter this arrangement as the Officer will be the most familiar with the individual’s case and best placed to address any issues raised by an individual prisoner. | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Post-Incident Response | 2018O10 | Death in Custody | A Critical Incident meeting should take place as soon as possible after a death in custody. | Accepted | 10/06/2020 | The Operations Directorate have a draft Critical Incident Management Booklet which is currently being developed. This booklet will address the recommendation of the Inspector. | Operations | Q3 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | |||||
| 27/11/2020 | 30/10/2018 | Midlands Prison | Post-Incident Response | 2018O11 | Death in Custody | The IPS Critical Incident Policy should be reviewed and consideration given to the inclusion of a cold debrief within 14 days of an 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, i.e. the debrief as soon as possible after the incident occurred. | Accepted | 10/06/2020 | The Operations Directorate have a draft Critical Incident Management Booklet which is currently being developed. This booklet will address the recommendation of the Inspector. | Operations | Q3 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | NA | |||||
| 08/05/2020 | 14/11/2018 | Midlands Prison | End of Life Care | 2018P1 | Death in Custody | The IPS should consider introducing a policy that would require written consent by a prisoner to confirm their wish not to be resuscitated. Appropriate safeguards should be put in place to ensure that such consent is fully informed and provided freely. | Accepted | 07/01/2020 | The IPS are in the process of developing an End of Life Care Policy which includes the issue of resuscitation as appropriate. Prisoners are given opportunities to engage in advanced planning where each prisoner is provided with appropriate information to make informed decisions and supported by someone who understands the complexities of the process as well as the clinical implications of the decisions. It is important to note that health care professionals in the IPS are also subject to the End of Life Care Guidelines as set by their Professional Bodies. | John Devlin, IPS Clinical Lead | Q1 2020 | NA | NA | NA | NA | NA | NA | NA | NA | NA | 31/12/2020 | IPS - Complete | End of Life Care Policy has been drafted and now circulated for consultation | |||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Escorts | Court | 2018X1 | Death in Custody | The IPS should take immediate action to ensure that an Escort departs a prison in sufficient time to arrive at a Court Sitting at least 15 minutes before that Court is due to commence thereby guaranteeing compliance with a Judicial Order of the Court. | Accepted | 03/07/2020 | The Prison Service Escort Corps already has in place a list of start times for each courthouse from each prison that take travel time and 15 mins prior to court as estimated time of arrival. It is critical that it is accepted that while every effort is made to be on time there are elements out of IPS’ control which impact on our planning and scheduling such as: traffic accidents or delays, extreme weather conditions, prisoner presenting as being unwell and requiring consultation with healthcare prior to departure, vehicle breakdowns etc. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Escorts | Staffing | 2018X2 | Death in Custody | The IPS should satisfy itself that the number of staff detailed for duty is adequate to convey prisoners from their landings to Reception and process them in a timely manner so that the departure of a Court escort is not delayed. If sufficient resources are detailed and they fail to carry out the duties to which they are assigned the officer(s) should be held to account. | Accepted | 03/07/2020 | PSEC have undertaken a Service Level Agreement with Castlerea Prison to ensure the timely collection and adequate resources in the processing of Prisoners before departure. It is intended that this model SLA be rolled out to all other relevant institutions. PSEC to review the workload of “ACOs outside Dublin” including piloting a new detailing process to assist them. | Operations Directorate. | Q3 2020 Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Escorts | Staffing | 2018X3 | Death in Custody | The IPS should consider the appropriateness of an Assistant Chief Officer who has oversight of a number of escorts also performing the role of Court Officer. | Accepted | 03/07/2020 | This matter will be considered in the context of the review of the workload of the ACOs outside Dublin. The Inspector will be informed of the outcome of this process. | Operations Directorate/ Human Resources | Q3 2020 | NA | NA | NA | 15/05/2023 | IPS - Complete | Completed 2020 | NA | NA | NA | NA | NA | NA | ||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Accommodation | Court | 2018X4 | Death in Custody | The IPS should consider entering discussions with the Courts Service regarding the provision of appropriate facilities in Courthouses, to include a holding cell(s) and a secure toilet, for use by prisoners while attending court. | Accepted | 03/07/2020 | There is ongoing engagement with the Court Service in this regard. This recommendation will be brought to the attention of the Courts Service. Since the start of the COVID-19 pandemic, the use of video link has increased significantly within the Prison Service. The total Video link cases completed year to date 5370, compared to 3798 for the 12 months of 2019. Overall in 2020, 39% of escorts this year to date have been carried out by way of Videolink. | IPS Director General | Complete 09/07/20 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Record-Keeping | Accuracy | 2018X5 | Death in Custody | The Officer in charge of the Court should ensure that all Court Return Forms are accurately completed to allow for the recording of the result of the Court on PIMS and the placement of the signed copy on the prisoner’s file. | Accepted | 03/07/2020 | These procedures are covered in the Escort Guidelines SOP, published in 2016. For administration reasons it is not practicable to hold a signed copy of all court return forms on a prisoners file. However, each prison is required to ensure that all records are accurately completed and filed in such a manner as they can be accessed at any time in the future for reference. Governor 1 Operations has written to All Governors to advise them of the responsibility to retain all court documentation on file for future reference. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Policies and Procedures | Implementation | 2018X6 | Death in Custody | An Officer in charge of a Court Escort must ensure that the individual before the Court is only released when s/he has properly checked all documentation and is satisfied that there are no grounds to detain the prisoner. Consideration should be given to a ‘double check’ system whereby the Officer-in-charge of the escort requests another officer on the escort to check all relevant documentation and both officers sign the Court Result Form to state that they both checked the documentation (date and time) prior to the release of the prisoner concerned. | Accepted | 03/07/2020 | A new SOP is currently being drafted which will take account of this recommendation. | Operations Directorate | End July 2020 | NA | NA | NA | 15/05/2023 | IPS - Complete | Completed 2020 | NA | NA | NA | NA | NA | NA | ||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Policies and Procedures | Implementation | 2018X7 | Death in Custody | The IPS should ensure that the Officer-in-charge of an escort has adequate time to check the documentation in relation to each prisoner on that escort prior to its departure from the prison in compliance with section 3.2 of the IPS SOP Escorting of Prisoners. Where sufficient time is allocated and s/he fails to comply with the IPS policy in relation to Escort Duties the officer(s) should be held to account. | Accepted | 03/07/2020 | Already in place - The Officer in charge is responsible for fulfilling their pre-departure checks, including checking and preparing the required paperwork for their escort. The assisting Officers are charged with collecting the prisoner(s) allowing the Officer in charge to liaise with the General Office, Chief Officer or ACO as required. It is a matter for individual Governors to address issues relating to breaches of discipline or non-performance of agreed duties. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Policies and Procedures | Implementation | 2018X8 | Death in Custody | The IPS should ensure that all Officers in charge of a Court Escort and those who assist in Court Escorts are fully aware of their responsibilities as outlined in the ‘Irish Prison Service Standard Operating Procedure Escorting of Prisoners’. | Accepted | 03/07/2020 | The IPS SOP Escorting of Prisoner forms part of the ongoing CPD training delivered to all staff on a regular basis. Staff that have not completed this training cannot participate in escort duties. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Policies and Procedures | Implementation | 2018X9 | Death in Custody | The IPS should enhance governance structures to ensure that their Policies, SOP’s, Governors and Chief’s Orders are (a) known to all staff and (b) implemented at all times. | Accepted | 03/07/2020 | A review and upgrade of Policy Framework is currently underway, and the implementation is currently being aligned to PRISM. It is the responsibility of the owners of the policies and SOP’s to ensure implementation. | Corporate Services Directorate | End 2020 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | 15/05/2023 | IPS - Complete | Completed 2020 | NA | NA | NA | NA | NA | NA | |||
| 12/10/2020 | 30/01/2018 | Castlerea Prison | Escorts | Training | 2018X10 | Death in Custody | The IPS should satisfy itself that staff detailed for Court Escort duties are appropriately trained to meet the demands of the various escort role(s) and responsibilities. | Accepted | 03/07/2020 | The IPS is satisfied that appropriate training is in place. PSEC staff participate in all required training including CPD (Escort Guidelines, Control & Restraint, use of Mechanical Restraints Manual Handling etc.), Occupational First Aid, and various elements of driver training. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 31/01/2022 | 27/01/2019 | Midlands Prison | Next-of-Kin | Visitation | 2019A1 | Death in Custody | IPS management should ensure that there is clear communication in advance to the family of a deceased person as regards the security requirements placed on them when entering a prison to collect person belongings; consideration should be given to all such meetings taking place in an area (such as the Visitors waiting area) where security screening is not required. | Part Accepted | 29/04/2021 | Operations management shall issue a circular regarding the importance of clear communication with the family of a deceased person regarding security requirements. Consideration will be given to the availability of areas where security screening is not required however it is important to note that this is not always an option depending on the location of the DIC. | Operations Directorate/ Chaplaincy/ Care and Rehabilitation | May 2021 | NA | NA | NA | 01/06/2023 | IPS-Complete | Operations Directorate issued Circular OPS/3/2021 on 4/8/2021 reminding staff that when a DIC occurs relatives are advised in advance of security arrangements. | 01/09/2022 | IPS - Ongoing | The Irish Prison Service intends to review all procedures with regard to engagement with families in the aftermath of a bereavement and develop a comprehensive Standard Operating Procedure for dealing with family members. A new SOP will be completed by the end of 2022 The Office of the Inspector of Prison will be consulted as part of the development process. ------- Q4 2022 | NA | NA | NA | ||||
| 31/01/2022 | 27/01/2019 | Midlands Prison | Next-of-Kin | Contact | 2019A2 | Death in Custody | The IPS should give consideration to reviewing the Protocol on ‘Chaplaincy and Notification of Next of Kin’ to provide for the assistance of An Garda Síochána in a situation where contact with the NoK cannot be made in person in a timely manner. | Accepted | 29/04/2021 | The Notification of Next of Kin protocol is to be reviewed when the arrangements for out of hours services by Chaplains is agreed with staff representatives. | Operations Directorate/ Chaplaincy/ Care and Rehabilitation | Q3 2021 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | The notification of Next of Kin protocol will be considered as part of the IPS development of a new Death in Custody Policy and related protocols. Notification by chaplains will be subject to agreement with staff representatives. | 01/06/2023 | IPS - Ongoing | The Chaplaincy review will commence in Q2 2023, this recommendation will be considered a part of this review. | 01/09/2022 | IPS - Ongoing | The Irish Prison Service intends to review all procedures with regard to engagement with families in the aftermath of a bereavement and develop a comprehensive Standard Operating Procedure for dealing with family members. A new SOP will be completed by the end of 2022 The Office of the Inspector of Prison will be consulted as part of the development process. ------- Q4 2022 | NA | NA | NA | |
| 21/09/2022 | 05/02/2019 | Midlands Prison | Chaplaincy | 2019B1 | Death in Custody | The Irish Prison Service should consider availability of chaplaincy services to prisoners during the reserve period from 17:00 to 20:00 (Rostered Hours) when school and workshops are closed and prisoners are unlocked. | Accepted | 26/05/2022 | The Irish Prison Service is currently considering availability of chaplaincy services to prisoners during the reserve period from 17:00 to 20:00 (Rostered Hours) when school and workshops are closed and prisoners are unlocked. The IOP recommendation will be further considered as part of the review of Chaplaincy services which will take place in Q2 2022. | Care and Rehabilitation Directorate | Q2 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Currently chaplaincy services to prisoners during the reserve period from 17:00 to 20:00 are on an ad hoc basis and, out-of-hours services in supporting prisoners and staff are provided as required. This recommendation will be further considered as part of the review of Chaplaincy services which is planned to take place in 2024. | 01/06/2023 | IPS - Ongoing | The Chaplaincy review will commence in Q2 2023, this recommendation will be considered a part of this review. | NA | NA | NA | NA | NA | NA | ||
| 21/09/2022 | 05/02/2019 | Midlands Prison | Record-Keeping | Accuracy | 2019B2 | Death in Custody | The Officer in charge of the landing should be obliged to record all concerns/incidents brought to his/her attention in the relevant Journal. The note should include the time of the report, who made the report, about whom and the nature of the concern to include action, if any taken. Such entries would ensure that all officers taking up duty on a landing and all supervising officers who check and sign the Journals are fully briefed. | Accepted | 26/05/2022 | Already in place In 2019 the Irish Prison Service carried out a review of the policy and Standard Operating Procedures with regard to the Monitoring of Prisoners during Periods of Lock Up. The revised documents were published on the IPS Intranet and a comprehensive communications plan was rolled out to raise awareness of same. All staff should be aware of their obligations/requirements to record and note any significant information in relation to the prisoners under their supervision in the appropriate journal. SOP 11/21 Close Supervision Cell section 4.1 states “The Governor must ensure information pertaining to all matters relating to a prisoner is recorded in a Close Supervision Log”. Further the SOP states “Each observation must be recorded in the log maintained in accordance with the protocol”. Operations Directorate intends to carry out a full a review of all Policies and Standard Operation Procedures in relation to the Monitoring of Prisoners during periods of Lock up in 2022 and this recommendation will be further considered as part of that review. | Operations Directorate | Q4 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | NA | NA | NA | 01/06/2023 | IPS - Complete | As advised in the action plan published in September 2022 this recommendation is already in place. | NA | NA | NA | NA | NA | NA | |
| 21/09/2022 | 05/02/2019 | Midlands Prison | Risk Assessment | 2019B3 | Death in Custody | A healthcare risk assessment should be completed prior to placing a prisoner on the Special Observation List to (i) determine his/her risk to self or others (ii) if the cell which they occupy is suitable accommodation as regards to potential hazards and (iii) whether any item(s) in the cell or item(s) in their possession create or heighten the risk. | Part Accepted | 26/05/2022 | The requirement for a healthcare risk assessment to (i) determine his/her risk to self or other is set out in SOP 21-059-S-001 Healthcare Special Monitoring, section 3.1.(b) states “Use of this intervention is only initiated based on a thorough clinical assessment which is conducted face to face with the person in custody, by a Registered Medical Practitioner or Nurse. Assessment already in place. The purpose of Healthcare Special Monitoring is to increase observations on the prisoner as the level of risk is determined to be lower than the threshold for placement in the Safety Observation Cell (SOC). Healthcare Special Monitoring is recommended in the knowledge of a prisoner continuing to reside in their normal accommodation. The historic practice of “stripping out” a cell of potential hazards ceased a number of years back as it was determined that if risks were that significant a more appropriate healthcare response would be warranted. If there were concerns that the prisoner’s current accommodation was inappropriate and posed a risk then placement in the SOC would be recommended post assessment. | Care and Rehabilitation Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 21/09/2022 | 05/02/2019 | Midlands Prison | Special Observation | Monitoring | 2019B4 | Death in Custody | A Doctor or a Nurse should review a prisoner on the Special Observation List on the morning following a prisoner being placed on the list to determine if s/he requires continued special observation. | Accepted | 26/05/2022 | Already in place The requirement to provide a clinical care plan and the recommended level of monitoring is set out in SOP 21-059-S-001 Healthcare Special Monitoring, Section 3.1.(e) states “If Healthcare Special Monitoring is required, there is a duty of care on Healthcare staff to provide an appropriate Clinical Care Plan to manage the clinical presentation in a safe and responsive manner. The formulation of the Care Plan will be undertaken in consultation with operational staff, to ensure that all relevant information is included in the Care Plan”. Section 3.1.(d) states “The recommended level of monitoring must be complied with until the prisoner is removed from Healthcare Special Monitoring by the Multidisciplinary Team. Further as per Setion 4.2 (h) “Continuation/deselection of inclusion on the Healthcare Special Monitoring list must be discussed and agreed at weekly MDT meeting. The frequency of clinical review is stipulated in the clinical care plan on commencement of Healthcare Special Monitoring. Review and follow up should be carried out as per the clinical care plan. All Healthcare Special Monitoring prisoners are reviewed by the Multi Disciplinary Team on a weekly basis. The Healthcare Directorate will remind Doctors/Nurses of their obligations to ensure prisons on Healthcare Special Monitoring are reviewed as per the Clinical Care Plan. | Care and Rehabilitation Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 21/09/2022 | 05/02/2019 | Midlands Prison | Special Observation | Monitoring | 2019B5 | Death in Custody | A Chief Officer and/or a Governor grade should visit prisoners on the Special Observation List during Governor’s Parade and record the visit to include the demeanour of the prisoner in the Special Observation Book. | Accepted | 26/05/2022 | Already in place. The requirement by Governors to visit prisoners on special observation on a daily basis is set out in SOP 11/21 Close Supervision Cell section 3.3.5 states “The Prison Governor must visit each prisoner accommodated in a Close Supervision Cell on at least a daily basis”. SOP 01/xx Safety Observation Cell section 4.4. h(i) states “The Governor or designate should visit a prisoner in a Safety Observation Cell at least daily”. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 21/09/2022 | 05/02/2019 | Midlands Prison | Record-Keeping | 2019B6 | Death in Custody | The Irish Prison Service should replace the Breakfast, Dinner Guard and Tea Guard Journals with one Class Journal in which all officers assigned to the landing make daily entries including to whom they hand over responsibility for the landing. | Accepted | 26/05/2022 | Operations Directorate intends to carry out a full review of all Policies and Standard Operation Procedures in relation to the Monitoring of Prisoners during periods of Lock up in 2022 and this recommendation will be considered as part of that review. | Operations Directorate | Q4 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Record management will be captured as part of the digitisation project under the new IPS Strategey 2023-2027. | 01/06/2023 | IPS - Ongoing | Due to unprecedented demands on the resources of the Operations Directorate it has not been possible to complete this review, we expect to make progress across Q2 and Q3. | NA | NA | NA | NA | NA | NA | ||
| 21/09/2022 | 05/02/2019 | Midlands Prison | Handover | Operational | 2019B7 | Death in Custody | When a Supervising Officer on ‘handover’ provides the Special Observation List to the Class Officer, Dinner Guard or Tea Guard (Receiving Officer) the names of those on special observation should be recorded in the relevant Class Journal signed and dated by both the Officer handing over the list and the Officer receiving the list to ensure there is no doubt as who is subject to checks at 15 minute intervals. | Not accepted | 26/05/2022 | This recommendation would result in duplication of effort and as such is not accepted. The observation list is readily and easily available in real time on PIMS which staff have access to. Prisoners name, wing, cell, frequency and type of monitoring is available to view on one screen. As part of the circulars referenced above, Operations will remind Governors of the importance of the special observation list and how they can easily access the list. | Operations Directorate | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 21/09/2022 | 05/02/2019 | Midlands Prison | Record-Keeping | Accuracy | 2019B8 | Death in Custody | When a prisoner is placed on the Special Observation List, whether in his/her own cell or in the Safety Observation Cell, the Safety Observation Book should be completed and healthcare staff should conduct two hourly checks as is required when a prisoner is placed in a Special Observation Cell. | Part Accepted | 26/05/2022 | The process for placing a prisoner on special observation list for Healthcare Special Monitoring is set out in SOP 21-059-S-001 Healthcare Special Monitoring, section 4.2.(c) and 4.2.(d) state “If a decision is made by health care staff to place the person in custody on Healthcare Special Monitoring, he/she must update PHMS accordingly, inform the Governor and Chief Officer, who must in turn inform relevant operational staff. All persons placed on the Healthcare Special Monitoring List are included on The Special Observation/ Monitoring List, in real time, on the Prisoner Information Management System (PIMS). The recommended level of monitoring is set out in SOP 21-059-S-001 Healthcare Special Monitoring, section 3.1.(d) states “The recommended level of monitoring must be complied with until the prisoner is removed from Healthcare Special Monitoring by the Multidisciplinary Team. The placing of someone on Healthcare Special Monitoring is completed on PHMS which transmits to PIMS and is amalgamated into the Operational Special Observation list on PIMS. The frequency of required clinical reviews will be determined by the Clinical Care Plan as not all Healthcare Special Monitoring will require a rigid time specific review. This is based on clinical assessment and professional judgement of the clinical team. | Care and Rehabilitation Directorate | NA | NA | NA | NA | 01/06/2023 | IPS - Complete | Relevant SOPs are in place to address this recommendation. | NA | NA | NA | NA | NA | NA | ||||
| 16/04/2021 | 16/03/2019 | Mountjoy Men's Prison | Escorts | Hospital | 2019C1 | Death in Custody | The IPS should review its procedures in relation to handcuffing and escort procedures regarding hospital escorts and consider making specific provision for safe and secure custody of gravely ill prisoners in a humane manner. | Accepted | 23/03/2021 | The Operations Directorate’s “Escorting of Prisoners Policy” was due for review in April of 2021. We will review this policy by April 2021 and take the recommendation on board. | Operations Directorate | April 2021 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | The initial draft of the IPS Escorting of prisoners Policy has been commenced and will be advanced by the new Governor I operations on appointment. | 01/06/2023 | IPS - Ongoing | Due to unprecedented demands on the resources of the Operations Directorate it has not been possible to progress policy discussions with the necessary stakeholders. We expect to make progress across Q2 and Q3. | 01/09/2022 | IPS - Ongoing | A review of the Escorting of Prisoners Policy had been due to take place but has been delayed due to Covid-19 and a long-term staff absence. It is anticipated that the review will commence early next year. | NA | NA | NA | |
| 17/11/2021 | 23/03/2019 | Wheatfield Prison | Healthcare | Committal | 2019D1 | Death in Custody | IPS should put in place appropriate controls to ensure adherence to the provisions of Rule 11 of the Prison Rules 2007-2017. | Accepted | 04/05/2022 | The Irish Prison Service will issue a reminder to Governors, Doctors and the Chief Nurse Officers to comply with Rule 11 and the Healthcare Standards on committal. | Care and Rehabilitation Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 17/11/2021 | 23/03/2019 | Wheatfield Prison | Healthcare | Committal | 2019D2 | Death in Custody | The admission to prison of a person subject to Rule 11, should be automatically notified to healthcare by triggering a notification on PIMS to the PHMS. This timely notification would alert healthcare so that the provisions of the Rule will be addressed within the required timeframes. | Accepted | 04/05/2022 | PIMS information is transferred automatically to PHMS in a matter of minutes. The Irish Prison Service will explore an IT solution that will trigger an automatic notification from PIMS to PHMS. | Operations Directorate / ICT | Q2 2021 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Operations, Healthcare and ICT will work together to seek a solution to this issue. Initial discussions have taken place. It is expected that this will be resolved in Q1 2024.] | 01/06/2023 | IPS - Ongoing | A meeting of the various stakeholders to discuss what is required to implement this change has been scheduled. | 01/09/2022 | IPS - Ongoing | Work on implementation of this recommendation was delayed due to Covid-19. Work on the development of the necessary action to implement this recommendation will recommence in Q3 2022. ------- Q4 2022 | NA | NA | NA | |
| 17/11/2021 | 23/03/2019 | Wheatfield Prison | Healthcare | Record | 2019D3 | Death in Custody | Medical and Nursing personnel should contemporaneously record medical and nursing interventions on the PHMS. | Accepted | 04/05/2022 | It is current practice that medical and nursing personnel contemporaneously record medical and nursing interventions on PHMS. The relevant procedure in Wheatfield Prison was amended to ensure that the Health Care Team have been alerted by phone of the arrival of a committal. | Care and Rehabilitation Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 17/11/2021 | 23/03/2019 | Wheatfield Prison | Special Observation | Monitoring | 2019D4 | Death in Custody | IPS should ensure compliance with its own SOP regarding observation of prisoners detained in Close Supervision Cells. | Accepted | 04/05/2022 | The Irish Prison Service will issue an Operational Circular to Governors reminding them of the SOP and their obligations. | IPS Director General | June 2021 | Q2 2024 | IPS - Complete | The SOP is adhered to locally and observations are recorded in the relevant journals, signed off daily by a Chief Officer and Governor. The policy document is on display in the West 2 Class Office. | 01/06/2023 | IPS - Ongoing | The review of the Prison Rules is ongoing, the advancement of this recommendation is contingent on the completion of this review. | 01/09/2022 | IPS - Ongoing | The Irish Prison Service issues reminders to staff on their obligations with regard to the monitoring of prisoners. All SOPs and policies are available on a bespoke Monitoring of Prisoners portal on the Irish Prison Service Intranet. The Irish Prison Service intends to publish a new policy and suite of SOPs on the Monitoring of Prisoners when the work on the updating of the Rule on the use of Special Observation Cells has been completed. ------- Q4 2022 | NA | NA | NA | ||||
| 17/11/2021 | 23/03/2019 | Wheatfield Prison | Special Observation | Monitoring | 2019D5 | Death in Custody | All persons who are to be subject to ‘Special Observation’ should be clearly identified on the ‘Special Observation List’, irrespective of where in the prison they are being accommodated. | Accepted | 04/05/2022 | The Irish Prison Service issued a suite of policies/procedures regarding the monitoring of Prisoner in 2019. The policies/procedures clearly set out the obligations on staff to ensure that all prisoners assigned Healthcare Special Monitoring or Security Special Monitoring are placed on the PIMS monitoring/ observation list. The ability to place a prisoner on the PIMS monitoring/ observation list is function that is available for all cells on the PIMS system. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 17/11/2021 | 23/03/2019 | Wheatfield Prison | Record-Keeping | Accuracy | 2109D6 | Death in Custody | When the IPS is checking random samples of CCTV footage it should ensure that written records are accurate as evidenced by CCTV footage. | Accepted | 04/05/2022 | The Irish Prison Service can confirm that the practice of checking random samples of CCTV is being completed by Chief Officers. The Irish Prison Service will issue a notice to Chief Officers reminding them of their obligations to check random samples of CCTV and ensure that written records accurately depict the CCTV footage viewed. Consideration will be given to putting an arrangement in place for the cross checking of CCTV checks with journal entries. | Operations Directorate | Ongoing | Q2 2024 | IPS - Complete | CCTV randomiser email is received daily and checked by Chief’s Office. Verification of the check is emailed to the Chief Officer 1, by the relevant Chief Officer 2.] | NA | NA | NA | 01/09/2022 | IPS - Ongoing | The IPS has established a group to examine the digitisation of records and this issue will be considered as part of the Groups work. In the interim, an Operational Circular reminding Chief Officers to carry out the random checks of CCTV will be reissued and a written recording process will be introduced pending the development of the electronic solution. ------- Q4 2022 | NA | NA | NA | ||||
| 17/11/2021 | 23/03/2019 | Wheatfield Prison | Record-Keeping | Accuracy | 2019D7 | Death in Custody | The IPS should ensure that accurate records are maintained and any failure to do so should be appropriately addressed. | Accepted | 04/05/2022 | Currently the process of recording the cell movements of a prisoner in a Special Observation Cell or Close Supervision Cell is manual. Prison management will remind all staff of their obligations to log and record all cell movements in Special Observation Cells or Close Supervision Cells and the importance of recording incidents promptly and accurately in the appropriate log book and electronic systems. An IT solution is being explored to facilitate a more effective and efficient logging process which will support accuracy. | Corporate Services / ICT | Completed To be confirmed | Q2 2024 | IPS - Complete | The CSC Policy has been completed and is pending clarification and deals with the issues herein. The Digitalisation Project will deal with manual recording of information. | 01/06/2023 | IPS - Ongoing | An IT solution continues to be explored, this is a long term matter for planning; solution development and deployment. | 01/09/2022 | IPS - Ongoing | Relevant officials have been identified to examine how the Irish Prison Service can streamline and improve the information management process in relation to logbooks and journals. The IPS intends to replace manual or written log books with the electronic recording of information. An IT solution is being explored to facilitate a more effective and efficient logging process which will support accuracy. | NA | NA | NA | ||||
| 10/08/2020 | 03/05/2019 | Limerick Prison | Temporary Release | Terms and conditions | 2019F1 | Temporary Release | The IPS should ensure that all persons receiving Reviewable Temporary Release (RTR) are made aware of the terms of their release in writing and that they sign the relevant form acknowledging their understanding of the terms of their release. A copy of the signed form should be retained by the Prison as evidence that this had been done. | Accepted | 10/06/2020 | It is standard practise that all prisoner receiving temporary release sign the temporary release form and had the conditions attached to the temporary release explained to them. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 10/08/2020 | 03/05/2019 | Limerick Prison | Healthcare | Committal | 2019F2 | Temporary Release | The IPS should put appropriate governance procedures in place to ensure that the required Doctors Committal Interview section in PHMS is completed and addresses the requirements of Rule 11 of the Prison Rules 2007-2017 for all persons admitted to Limerick Prison. | Accepted | 10/06/2020 | “All doctors working in a prison, both staff and locum doctors are required to complete the Doctors Committal Interview on PHMS, as part of the medical committal process, in line with good record keeping requirements and have been reminded of this on a number of occasions. The Executive Clinical Lead has reminded the doctor in Limerick Prison of the requirement in this regard”. | Healthcare | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 04/02/2022 | 24/06/2019 | Cork Prison | Post-Incident Response | Supports | 2019H1 | Death in Custody | Every effort should be made to ensure that all those involved in a serious adverse incident resulting in a death participate in the subsequent debriefing sessions to ensure they are afforded an opportunity to process the event and reflect on its impact. | Accepted | 05/11/2021 | None – This is included in the Critical Incident Operational Reporting and Debrief Procedures SOP issued in July 2020 None – Following the incident, a critical incident protocol was implemented in Cork Prison. The Governor spoke to all staff directly involved and offered them support services. The local Staff Support Officer engaged with them all. In July 2019, the Critical Incident Stress Management (CISM) Policy became active and has been used since in the event of any critical incidents. | Operations Directorate Human Resources | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 04/02/2022 | 24/06/2019 | Cork Prison | Next-of-Kin | Contact | 2019H2 | Death in Custody | The IPS should ensure all staff are aware of and implement Prison Rule 4 (Prison Rules 2007-2020) which relates to the recording of prisoner’s details. Prison Rule 4 states that particulars relating to the admission of each prisoner shall be recorded by a person designated by the Governor upon his/her admission to a prison. Prison Rule 4 (e) refers to the recording on PIMS of full details of the NoK and states that the following should be included: “…contact details for either, (i) a parent or lawful guardian of a prisoner under 18 years of age or, (ii) such member of the prisoner’s family as the prisoner may nominate, or (iii) such other person as the prisoner may nominate.” | Accepted | 05/11/2021 | Next of Kin details - when provided by a prisoner - are recorded for all prisoners as part of the Governor’s Committal interview. This facility was developed into the Prisoner Information Management System (PIMS) as part of the Risk Assessment release in 2018. SOP - Administration of processing a Prisoner at Reception covers the recording of prisoner details including Next of Kin. SOP is due for review in August 2022. In addition, Operations have made a report available to all prisons which will identify prisoner's next of kin details and when they have last been updated to allow them to keep them up to date. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 04/02/2022 | 27/06/2019 | Limerick Prison | Information | Share with Parole Board | 2019I1 | Death in Custody | In order to prevent unnecessary adjournments of Parole Board hearings IPS staff should ensure that all documentation required by the Parole Board is provided well in advance of a scheduled hearing date. | Accepted | 20/10/2021 | The current Parole Board is due to be stood down in June of 2021. Further discussions will be required with the new board to allow the IPS to understand any new requirements which they may have. In addition, it should be noted however that the Probation Service and the Gardaí are also required to send in reports to the Parole Board. This is not a matter for the Irish Prison Service. The Irish Prison Service will engage with the new Statutory Parole Board in relation to the timely submission of prison service documentation. | Operations | NA | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | The IPS have an agreement in place with the Parole Board with regard to the submission of material and the IPS will comply with the provision of this agreement. | NA | NA | NA | ||||
| 04/02/2022 | 27/06/2019 | Limerick Prison | Post-Incident Response | Evidence | 2019I2 | Death in Custody | Prisoners sharing a cell where a serious incident occurred should not be relocated to a cell with another prisoner as vital evidence could be contaminated or lost. | Part Accepted | 20/10/2021 | It is accepted that in most circumstances a prisoner who shared a cell where a serious incident occurred should not relocate to another shared cell. However Prison numbers are rising and on any one occasion, there may not be a free cell readily available and while it may be possible on most occasions to relocate prisoners to a single cell, there may be occasions when this is not possible. | Operations | NA | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | Recommendation in place. The requirement to remove and isolate other prisoners from the cell is set out in Appendix 2 – Death in Custody – Action Checklist which forms part of SOP 11/019 Death in Custody. Where a serious incident occurs, prisoners are searched, clothes removed for evidence and prisoners are placed in a free cell. This would be standard practice. | NA | NA | NA | ||||
| 04/02/2022 | 27/06/2019 | Limerick Prison | Healthcare | CPR training | 2019I3 | Death in Custody | The Irish Prison Service should consider including Basic Life Support (BLS) training for recruit prison officers during the early part of their training and refresher courses for established staff. | Not accepted | 20/10/2021 | When the IPS developed the current syllabus for Recruit Prison Officer training in 2016, it was decided not to include first responder training in the programme. This was because of the demands this would place on the staffing system for refresher training each year. The initial training takes 3 days to deliver and a further 1 day refresher is required every two years thereafter. The drain on resources from the requirement to provide refresher training would seriously impact on staffing and the provision of other resources. Considerations 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 callout. First responder training is however provided to Gym Officers, PSEC Staff and Open Centre staff. With all that being said it should be recognised that a nurse would usually be one of the first people on the scene in these situations. Basic Life Support and First Responder Training is a core element of the skillset of all nurses employed in the prison service. | IPS Training College | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 04/02/2022 | 27/06/2019 | Limerick Prison | Healthcare | Privacy | 2019I4 | Death in Custody | In situations where a prisoner has to be removed to the landing to allow for medical intervention privacy screen(s) should be available to protect the privacy of all involved. | Accepted | 20/10/2021 | The Irish Prison Service is currently arranging to purchase privacy screens for the entire prison estate. A supplier has been identified and the medical teams in each prison have been asked to provide their requirements for screens. | Healthcare | August 2021 | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | Procurement process for the supply of privacy screens has been completed. | NA | NA | NA | ||||
| 16/04/2021 | 27/07/2019 | Midlands Prison | Accommodation | Call bell | 2019K1 | Death in Custody | A portable alert device should be available to prisoners who are incapacitated and incapable of reaching the in-cell call bell alert system. | Accepted | 10/03/2021 | A suitable and appropriate cell call system for people with reduced mobility will be identified by the Irish Prison Service. This will facilitate prisoners to alert staff from all areas of the cell accommodation. This facility will be integrated into any cell allocated for people with disabilities. | Care and Rehabilitation Directorate / Building Services Division | New system to be identified and approved by end of May 2021. Installation across the estate to be completed by end OCT 2021. | Q2 2024 | IPS - Complete | Midlands Prison has made provision for individuals with mobility challenges to have a cell call placed within reach. | 01/06/2023 | IPS - Ongoing | There are a number of trial sites in operation. A review of these will take place Q4 2023 | 01/09/2022 | IPS - Ongoing | Work on the installation of an appropriate system stalled due to the covid-19 pandemic. Consideration of the action required to implement an appropriate system will be progressed in Q4 2022 and Q1 2023 with a view to introducing a new system as soon as possible. ------- Q1 2023 | NA | NA | NA | ||||
| 21/01/2022 | 01/08/2019 | Mountjoy Men's Prison | Temporary Release | Terms and conditions | 2019L1 | Temporary Release | The IPS should ensure that all persons receiving Reviewable Temporary Release (RTR) sign the relevant form acknowledging their understanding of the terms of their release and that the form is signed by a witness who also print their name in block capitals. | Accepted | 08/07/2021 | Operations directorate will issue a circular to all Governors reaffirming the RTR signing procedure. | Operations Directorate | June 2021 | NA | NA | NA | NA | NA | NA | 01/09/2022 | IPS - Complete | An Operations circular issued in July 2021 setting out this requirement. | NA | NA | NA | ||||
| 21/01/2022 | 01/08/2019 | Mountjoy Men's Prison | Temporary Release | 2019L2 | Temporary Release | The IPS should consider introducing a system whereby the TR form is printed from the PIMS when the person on TR arrives at the prison to sign on. When the form is signed and witnessed it is immediately scanned and recorded on PIMS. | Part Accepted | 08/07/2021 | TR forms are printed in bulk, it would not be feasible to print each form as the prisoner arrives at the prison. The form is signed and witnessed. Operations will include the process of the scanning of all RTR forms and recording on PIMS in the RTR circular to be issued. | Operations Directorate | June 2021 | NA | NA | NA | 01/06/2023 | IPS - Complete | The process of scanning RTR forms has been reviewed and it has been determined that due to the number of temporary release forms involved, it is not feasible at present. We will keep this in mind for any future releases on PIMS and/or our TR processes. | 01/09/2022 | NA | Not accepted | NA | NA | NA | |||||
| 28/09/2022 | 01/08/2019 | Wheatfield Prison | Record-Keeping | 2019M1 | Death in Custody | IPS Management must ensure that all sections of Official Journals are fully and comprehensively completed in legible handwriting and all signatures are supported by block capitals. Furthermore, that regular audits of all records is carried out to ensure compliance. | Accepted | 26/05/2022 | In 2019 the Irish Prison Service carried out a review of the policy and Standard Operating Procedures with regard to the Monitoring of Prisoners during Periods of Lock Up. The revised documents were published on the IPS Intranet and a comprehensive communications planned was rolled out to raise awareness of same. The requirement for the recording of information in the Close Supervision Log is set out in Standard Operation Procedure 11/21 - Close Supervision Cell which states “the Governor must ensure that information pertaining to all matters relating to the prisoner is recorded in the Close Supervision Log in accordance with the SOP. All staff should be aware of their obligations/requirements to record and note any significant information in relation to the prisoners under their supervision in the appropriate journal. Operations Directorate intends to carry out a full review of all Policies and Standard Operation Procedures in relation to the Monitoring of Prisoners during periods of lock up in 2022 and this recommendation will be considered as part of that review. In the interim, Operations Directorate will issue a reminder to all staff regarding the need to ensure that all appropriate information is recorded in the appropriate journals. | Operations Directorate | Q4 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Journals are completed as required and checked and signed off on a daily basis by a Chief Officer and/or Governor. Record management will be captured as part of the digitisation project under the new IPS Strategey 2023-2027. | 01/06/2023 | IPS - Ongoing | Due to unprecedented demands on the resources of the Operations Directorate it has not been possible to progress policy discussions with the necessary stakeholders. We expect to make progress across Q2 and Q3. | NA | NA | NA | NA | NA | NA | ||
| 28/09/2022 | 01/08/2019 | Wheatfield Prison | Record-Keeping | 2019M2 | Death in Custody | The issuing of Official Journals should be recorded in a master file showing date of issue, by who, date received and by who, location and date of completion. Only officers of ACO or above should sign for these books. | Accepted | 26/05/2022 | Relevant officials will examine how best to streamline and improve the information management process in relation logbooks and journals. The scope of the review associated with the management of journals across the estate includes: 1. Types of journals 2. Fields in the journals 3. Issuing of journals to prisons 4. Issuing of journals within prisons 5. Central recording of same – numbers on the journals; when issued; to whom; by whom; date received; location; date journal completed; retention of journal; 6. Are current journals fit for purpose? 7. Are digital journals possible? The review will produce a clearly documented process for issuing and recording of logbooks/journals and information management of same. | Corporate Services Directorate | Q1 2023 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Currently, all Class Journals are issued from the General Office and returned to Chief’s Office when full. Night duty and meal break journals are issued from the Chief’s Office and returned there when full. From Q1 2024, a new procedure will be in place whereby all journals will be issued and returned on a monthly basis, to/from the Chief’s Office. This monthly issue and return of journals will be recorded electronically, in a folder on our local shared drive. Digitalise Prison Report Books With the support of the Change, Technology & Innovation unit in the Department of Justice, work continued in 2023 on the planning for digitalising prison report books. To support designing and identifying a solution workshops took place with stakeholders to assess the current status of prison reports, examine the hierarchy of reports and the amount of duplication contained in reports. A wireframe of components for a potential solution and the relationships that each component should have with databases and each other has been developed. This will support work in 2024 to scope a potential solution that could be tailored to suit the needs and objectives for staff and services. Developing and implementing a solution is contingent on resource and budget. | 01/06/2023 | IPS - Ongoing | This review is ongoing. | NA | NA | NA | NA | NA | NA | ||
| 28/09/2022 | 01/08/2019 | Wheatfield Prison | Contraband | 2019M3 | Death in Custody | Officers on supervisory duty in charge of the exercise yard should respond when prohibited article(s) are thrown onto the netting and make every effort to ensure that contraband is not secured by prisoners. | Under Review | 26/05/2022 | A meeting is required with the IOP to discuss this matter further. Based on a dynamic risk assessment the appropriate action is taken in response to such events. | Operations Directorate | NA | NA | NA | NA | 01/06/2023 | IPS - Complete | Based on a dynamic risk assessment the appropriate action is taken in response to such events. | NA | NA | NA | NA | NA | NA | |||||
| 28/09/2022 | 01/08/2019 | Wheatfield Prison | Post-Incident Response | Evidence | 2019M4 | Death in Custody | Prisoners sharing a cell where a serious incident occurs should not be placed with other prisoners when removed from that cell as vital evidence could be contaminated or lost. | Accepted | 26/05/2022 | Recommendation in place. The requirement to remove and isolate other prisoners from the cell is set out in Appendix 2 – Death in Custody – Action Checklist which forms part of SOP 11/019 Death in Custody. Where a serious incident occurs, prisoners are searched, clothes removed for evidence and prisoners are placed in a free cell. This would be standard practice. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 28/09/2022 | 01/08/2019 | Wheatfield Prison | Contraband | 2019M5 | Death in Custody | The recommendation in relation to cell searches in our death in custody investigation report Mr K 2018 is also applicable as a recommendation in this report i.e. that the IPS should conduct regular routine and unannounced cell searches for illicit material. The results should be made available to the Inspector of Prisons for the purposes of Death in Custody investigations. | Accepted | 26/05/2022 | Recommendation in place. Insofar as resources allow, targeted (cell specific) and general area searches of prisons occur on a regular basis with the aim of retrieving contraband. OSG regularly provide Operations and the Statistics Unit with contraband seizure figures. These figures are now available on the Prison Service website. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 21/01/2022 | 09/12/2019 | Cloverhill Prison | Escorts | Hospital | 2019Q1 | Death in Custody | IPS should review its procedures in relation to hospital escorts of gravely ill prisoners and particularly the necessity for a three person escort of a prisoner who is in custody pending the payment of a small bail bond of €100. | Under Review | 25/11/2021 | To be considered in the context of the Policy and procedure review. All relevant Policy and procedures in respect of prisoner escorts will be reviewed by end of Q3 2021. Any proposed amendments will be communicated to Prison Governors for implementation. To note: The Irish Prison Service is required to ensure that all those placed in its custody are held safely and securely. The IPS follows a risk management approach. Prisons have options/ability to amend escort numbers on a risk assessed basis. Examples of such risks would include flight risk and a risk to public safety, etc. | Operations Directorate Prison Governors | End Q3 2021 | Q2 2024 | IPS - Complete | No further action from action plan commitment. | 01/06/2023 | IPS - Ongoing | Due to unprecedented demands on the resources of the Operations Directorate it has not been possible to progress policy discussions with the necessary stakeholders. We expect to make progress across Q2 and Q3 2023. | 01/09/2022 | IPS - Ongoing | The Irish Prison Service intends to review all procedures with regard to engagement with families in the aftermath of a bereavement and develop a comprehensive Standard Operating Procedure for dealing with family members. A new SOP will be completed by the end of 2022. ------ Q4 2022 | NA | NA | NA | ||||
| 21/01/2022 | 09/12/2019 | Cloverhill Prison | Record-Keeping | 2019Q2 | Death in Custody | All prison staff should be required to insert their name in block capitals beside their signature when completing all written records including prison journals. | Under Review | 25/11/2021 | Feasibility to be assessed. Engagement will take place with Governors/IPSC to give further consideration to this recommendation. Any proposed changes will be communicated to Prison Governors for implementation. | Operations Directorate Prison Governors | Issue to be determined by end September 2021 End Q3 2021 | NA | NA | NA | 01/06/2023 | IPS - Complete | Feasibility of this recommendation has been assessed and it is not practicable at present. A project is commencing to digitalise some of the report books which will resolve some of the issues which have arisen. | 01/09/2022 | IPS - Ongoing | Work on implementation of this recommendation was delayed due to Covid-19. Work on the development of the necessary action to implement this recommendation will recommence in Q3 2022. ------ Q4 2022 | NA | NA | NA | |||||
| 21/01/2022 | 09/12/2019 | Cloverhill Prison | Next-of-Kin | Visitation | 2019Q3 | Death in Custody | When Next of Kin are notified that their relative/friend has been hospitalised they should be, at that time, advised that only those persons named on the Prisoner’s Visitor list will be permitted to visit the person while in hospital. | Under Review | 25/11/2021 | To be considered in the context of the Policy and procedure review. This matter will be considered in the context of the policy and procedure review which will be completed by end Q3 2021. | Operations Directorate / Chaplaincy / Care and Rehabilitation Directorate | End Q3 2021 | Q2 2024 | IPS - Complete | No further action from action plan commitment. | 01/06/2023 | IPS - Ongoing | As per response provided Rec ID: Mr. Q 2019Q1, this recommendation will be progressed and completed in 2023. | 01/09/2022 | IPS - Ongoing | This matter will be considered in the context of the review set out in response to recommendation Mr A19-1. "The Irish Prison Service intends to review all procedures with regard to engagement with families in the aftermath of a bereavement and develop a comprehensive Standard Operating Procedure for dealing with family members. A new SOP will be completed by the end of 2022. The Office of the Inspector of Prison will be consulted as part of the development process." ------ Q4 2022 | NA | NA | NA | ||||
| 21/01/2022 | 09/12/2019 | Cloverhill Prison | Next-of-Kin | Visitation | 2019Q4 | Death in Custody | Where a decision is made to disallow hospital visits, the patient should be informed as to the reason why the visit(s) is/are disallowed and whether the decision was made by hospital or prison personnel so that s/he, if they wish, may inform their relatives/friends. | Under Review | 25/11/2021 | To be considered in the context of the Policy and procedure review. This matter will be considered in the context of the policy and procedure review which will be completed by end Q3 2021. | Operations Directorate / Chaplaincy / Care and Rehabilitation Directorate | End Q3 2021 | Q2 2024 | IPS - Complete | No further action from action plan commitment. | 01/06/2023 | IPS - Ongoing | As per response provided to Rec ID: Mr. Q - 2019Q1, this recommendation will be progressed and completed in 2023 | 01/09/2022 | IPS - Ongoing | This matter will be considered in the context of the review set out in response to recommendation Mr A19-1. "The Irish Prison Service intends to review all procedures with regard to engagement with families in the aftermath of a bereavement and develop a comprehensive Standard Operating Procedure for dealing with family members. A new SOP will be completed by the end of 2022. The Office of the Inspector of Prison will be consulted as part of the development process." ------ Q4 2022 | NA | NA | NA | ||||
| 21/01/2022 | 09/12/2019 | Cloverhill Prison | Post-Incident Response | 2019Q5 | Death in Custody | A Critical Incident debrief should be convened following all deaths of persons in prison custody who are on a Hospital Order to review any issue(s) which arose during the persons time in hospital. | Under Review | 25/11/2021 | To be considered in the context of the Policy and procedure review. This matter will be considered in the context of the policy and procedure review which will be completed by end Q3 2021. For local implementation. | Operations Directorate / Chaplaincy / Care and Rehabilitation Directorate | End Q3 2021 | Q2 2024 | IPS - Complete | Implemented locally. | 01/06/2023 | IPS - Ongoing | As per response provided to Rec ID: Mr. Q 2019Q1, this recommendation will be progressed and completed in 2023 | 01/09/2022 | IPS - Ongoing | This matter will be considered in the context of the review set out in response to recommendation Mr A19-1. "The Irish Prison Service intends to review all procedures with regard to engagement with families in the aftermath of a bereavement and develop a comprehensive Standard Operating Procedure for dealing with family members. A new SOP will be completed by the end of 2022. The Office of the Inspector of Prison will be consulted as part of the development process." ------ Q4 2022 | NA | NA | NA | |||||
| 25/02/2022 | 27/12/2019 | Midlands Prison | Escorts | Hospital | 2019T1 | Death in Custody | It is recommended that a review of the current practice regarding a three person hospital escort be undertaken having particular regard to end of life hospital supervision. The review should consider the need for a risk assessment of the person to be hospitalised. | Not accepted | 09/12/2021 | In accordance with the Irish Prison Service “Escorting of Prisoners Standard Operating Procedures” a hospital escort can consist of 2 or 3 Officers. Decision making in respect of the appropriate staff compliment is a matter for local management taking into account the risks involved in the specific escort. On this basis, the Irish Prison Service does not believe that there is a necessity to reive the escort guidelines at this time. | Operations Directorate | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Information | Share with prison staff | 2019X1 | Death in Custody | Vulnerability: Where a ‘shared vulnerable cell’ is recommended this should be made known to all prison staff with a responsibility and duty of care for the detained person and recorded in relevant journals. | Accepted | 26/05/2022 | From the healthcare committal assessment, where it is deemed appropriate that a shared cell would mitigate any possible risk of self-harm the clinician undertaking this assessment should notify colleagues of all disciplines of the risk relevant information and any signature presentations to be aware for which would require immediate escalation to healthcare to reassess and provide safeguards. All Healthcare staff to be advised of same. | Care and Rehabilitation Directorate | Ongoing | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | 01/06/2023 | IPS - Complete | An updated instruction outlining this recommendation was issued to all Healthcare Staff by the Chief Nurse Officer of the Dochas Centre in Q1 2023. | NA | NA | NA | NA | NA | NA | |
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Risk Assessment | 2019X2 | Death in Custody | If it is decided a ‘shared vulnerable cell’ is no longer required a risk assessment should be conducted to justify de-escalation. This should be recorded on the detained persons PIMS record. | Accepted | 26/05/2022 | The healthcare risk assessment to deescalated from this requirement will be based on a healthcare risk assessment and as such will be recorded in the PHMS (healthcare notes). A follow up on the previous notification to other disciplines will be required to inform that this mitigation measure has been stepped down. All Healthcare staff to be advised of same. | Care and Rehabilitation Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Policies and Procedures | Implementation | 2019X3 | Death in Custody | The IPS should review self-harm policies at the Dóchas Centre considering SADA Reports and the National Strategy for Prevention of Suicide. | Accepted | 26/05/2022 | The Irish Prison Service are in the process of implementing a new intervention approach (CAMS) in the Dochas in Q2 2022, based on the outcomes of the SADA research. This programme of implementation of CAMS is being supported in design and implementation by the National Office of Suicide Prevention. | Care and Rehabilitation Directorate | Q2 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | 01/06/2023 | IPS - Complete | The final focus group meeting was held in Q1 2023, the Irish Prison Service are awaiting the implementation plan. | NA | NA | NA | NA | NA | NA | |
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Information | Share with prisoners | 2019X4 | Death in Custody | As required under Prison Rule 13, the IPS should ensure that all prisoners ‘shall upon admission to prison’ be provided with a leaflet of their rights and entitlements. To achieve this the IPS should conduct a review of all committal areas and prisons for the availability of these information leaflets in English, Irish and other languages. Prison Governors should check compliance with this Prison Rule during their regular inspections of a prison. | Part Accepted | 26/05/2022 | The Irish Prison Service produces a comprehensive Prisoner Information Booklet which is made available to all committals to prison. The book contains general information about prison life, staff, and regimes and services. The book is available in 8 languages and is updated on a regular basis. Work on the 2022 edition is ongoing and will be completed shortly. The Irish Prison Service will conduct an audit to ensure that the booklet is being made available in all prisons to new committals. In addition, the Irish Prison Service is giving consideration to the development of a Prisoner Information Programme to be broadcast on the TV Channel. Subject to funding this work will commence following the publication of the 2022 edition. | Corporate Services Directorate | Q3 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | The revised committal information booklet will be printed and distributed by end of Q3 2024. | 01/06/2023 | IPS - Ongoing | The Irish Prison Service conducted an audit on the availability of the Prison Information Booklet to prisoners on committal to prisons. The audit confirmed that all closed locations offer the Prisoner Information Booklet as part of the committal process. Some locations offer an additional information leaflet in different languages with more condensed information, further some have digital versions they use on the prisoner TV Channel. The open centres prisoners are advised as part of the Governors committal interview that the prisoner information booklet is still available in the prison library. The Irish Prison Service has revised and updated the Prisoner Information Booklet. It is expected that the English version will be available in all prisons in the coming weeks. Arrangements are being made to have the booklets translated into the most common languages used. | NA | NA | NA | NA | NA | NA | |
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Record-Keeping | Prisoner movement | 2019X5 | Death in Custody | A Person Escort Record should be introduced and completed for every movement of a prisoner into or out of a prison whether by Irish Prison Service staff or Gardaí. This should include details of risks of self-harm and vulnerability in addition to security considerations and include any comments or threats made by a detained person. | Accepted | 26/05/2022 | Historically, An Garda Siochana provided information on a form known as a C63 form. This form contained details of background information on the prisoners convictions, habits and some health information. This form is still used and provided in certain prisons but its use is not widespread nor is there a formalised agreement between both organisations on same. In 2021, an information sharing group was established to look at information sharing between various Justice bodies, they have begun the process of looking at the sharing of risk relevant information including the C63 form. The Irish Prison Service will bring this recommendation to the attention of the Information sharing group for consideration. | Operations Directorate | Q4 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | The Irish Prison Service has been engaging with An Garda Síochana with regard to the exchange of information including information provided between organisations. | 01/06/2023 | IPS - Ongoing | The Irish Prison Service and An Garda Siochana met in late April to discuss this issue and others. A review of the shared UAL Protocol has commenced, this review will take account of changes to the AGS operating model and identify up-to-date Garda Liaison Officers for each prison. As part of this review, consideration will be given to establishing new centralised reporting email structures between the two organisations, while the CJOH (Criminal Justice Information Hub) solution is forthcoming. | NA | NA | NA | NA | NA | NA | |
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Record-Keeping | Accuracy | 2019X6 | Death in Custody | All journals should be corporate, serial numbered, and completed in a policy led manner that is accurate, detailed and consistent across the IPS. This policy should include instructions for prison officers of information that should be recorded. | Accepted | 26/05/2022 | Relevant officials will examine how best to streamline and improve the information management process in relation logbooks and journals. The scope of the review associated with the management of journals across the estate includes: 1. Types of journals 2. Fields in the journals 3. Issuing of journals to prisons 4. Issuing of journals within prisons 5. Central recording of same – numbers on the journals; when issued; to whom; by whom; date received; location; date journal completed; retention of journal; 6. Are current journals fit for purpose? 7. Are digital journals possible? The review will produce a clearly documented process for issuing and recording of logbooks/journals an information management of same. | Corporate Services Directorate | Q1 2023 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Record management will be captured as part of the digitisation project under the new IPS Strategy 2023-2027. | 01/06/2023 | IPS - Ongoing | This review is ongoing. | NA | NA | NA | NA | NA | NA | |
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Post-Incident Response | Evidence | 2019X7 | Death in Custody | In the event of a death in custody the governor of the prison should seize and securely store all relevant original journals and issue new books. | Accepted | 26/05/2022 | The current SOP for Deaths in Custody only require the Governor to provide copies of any relevant journal. Operations will review the current SOP and amend to reflect this recommendation | Operations Directorate | Q4 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | There is a review of DIC protocols ongoing which will ensure the implementation of this recommendation. | 01/06/2023 | IPS - Ongoing | Due to unprecedented demands on the resources of the operations directorate it has not been possible to progress policy discussions with the necessary stakeholders. We expect to make progress across Q2 and Q3. | NA | NA | NA | NA | NA | NA | |
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Complaints | 2019X8 | Death in Custody | IPS policy should mandate all complainants be formally informed of progress of their complaint, including a decision not to investigate an allegation and the reason for discontinuance. | Accepted | 26/05/2022 | The Irish Prison Service PrisonerComplaints policy and Rule 57(b)(5)(b) provides for notification to the complainant in the event that a decision is taken not to proceed with the complaint. This did not happen in this case because of legal complications surrounding the initial decision to categorise the complaint as a Category A complaint. The Irish Prison Service is currently engaged with the Department of Justice in relation to legislation to establish a new prisoner complaints system. Any policy emanating from this legislation will ensure that this recommendation is implemented. It is not proposed to review or amend the current prisoner complaints policy. | Operations Directorate | Q4 2022 | Q2 2024 | IPS - Complete | No further action required. | 01/06/2023 | IPS - Ongoing | The position remains unchanged. | NA | NA | NA | NA | NA | NA | |||||
| 10/11/2022 | 14/10/2019 | Dóchas Centre | Post-Incident Response | 2019X9 | Death in Custody | The IPS should conduct a critical incident review following any death that is to be investigated by the OIP. | Accepted | 26/05/2022 | The Critical Incident Operational Reporting and Debrief Procedures defines a Death in Custody as a critical incident requiring review and the SOP for Deaths in Custody also places a requirement on prison Governors to provide the IOP with minutes of the critical incident review. Operations will review both documents and remind prison staff of their obligations and responsibilities by way of an Operational Circular. | Operations Directorate | Q4 2022 | Q2 2024 | IPS - Complete | No further action required. | 01/06/2023 | IPS - Ongoing | Due to unprecedented demands on the resources of the Operations Directorate it has not been possible to complete this review, we expect to make progress across Q2 and Q3. | NA | NA | NA | NA | NA | NA | |||||
| 30/06/2022 | 12/02/2020 | Cork Prison | End of Life Care | Compassionate temporary release | 2020A1 | Temporary Release | Decisions for compassionate temporary release, especially where end of life care is being administered, should be decided expeditiously to respect dignity in death for the prisoner and for a family to be allowed privacy. Once an application is made by a Governor, policy should dictate the timeframes for responses and escalation where delays occur. | Not accepted | 12/04/2022 | “Compassionate temporary release on grounds of health and health related humanitarian grounds”, requires the gathering of a wide range of information from multiple sources and with a number of checkpoints along the way. In addition, each case must be treated on its merits and the decision making must reflect the prisoner’s sentence, time in custody, nature of offence and other criteria. This recommendation is being rejected because placing timelines could lead to poor decision making as the policy. From a Healthcare perspective, it is also unrealistic to impose a strict deadline on this kind of process. Clarification on the relevant details would generally be required. Therefore a measure of flexibility would be necessary to ensure all the details have been collated and considered appropriately. However it is the case that staff will always endeavour to achieve an outcome as soon as is feasible. Depending on the sentence type the final decision maker is the Minister or the Director General of the Irish Prison Service and so in main there is no further escalation point. As such, the inclusion of timelines is not considered appropriate. | Operations Directorate Healthcare Directorate | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 30/06/2022 | 12/02/2020 | Cork Prison | Post-Incident Response | Debriefing | 2020A2 | Temporary Release | Every effort should be made to ensure that all those involved in the incident participate in the debriefing sessions (critical incident review) to ensure they are afforded an opportunity to process the event and reflect on its impact. | Accepted | 12/04/2022 | The Irish Prison Service Standard Operating Procedure (SOP) titled ‘Critical Incident Reporting and Debriefing Procedures’ came into effect on 1 July 2020 now reflects this requirement. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 30/06/2022 | 12/02/2020 | Cork Prison | End of Life Care | Compassionate temporary release | 2020A3 | Temporary Release | When temporary release is permitted on compassionate grounds, such as end of life care, the conditions attached to CTR should be proportionate, and reflect the situation of the prisoner and respect sensitivities of the family. | Accepted | 12/04/2022 | Compassionate Temporary Release Policy can be reviewed and amended to reflect this. It should be noted that the standard conditions of temporary release are governed by S.I. No. 680/2004 ‐ Prisoners (Temporary Release) Rules 2004. | Operations Directorate | Q2 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | Compassionate Temporary Release updated. | 01/06/2023 | IPS - Ongoing | Due to unprecedented demands on the resources of the Operations Directorate it has not been possible to complete this review, we expect to make progress across Q2 and Q3 2023. | NA | NA | NA | NA | NA | NA | |
| 30/06/2022 | 12/02/2020 | Cork Prison | End of Life Care | 2020A4 | Temporary Release | The IPS should establish an end of life and palliative care policy. | Accepted | 12/04/2022 | The Irish Prison Service has circulated the End of life Ethical Framework document to all prison Governors. | Healthcare Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 11/07/2024 | 11/03/2020 | Wheatfield Prison | Mental Health | Policy review | 2020C1 | Death in Custody | Posters displaying information about the support services/programmes available to prisoners experiencing mental health issues should be rolled-out across the Irish Prison Service estate. Governor grade staff should regularly verify that such posters remain in place. | Partially Acepted | 12/04/2024 | A Mental Health & Addiction Lead will be appointed in Q2 2024. This individual will work with each Governor and relevant in-reach service who provide a mental health / addiction service e.g. Samaritans, Red Cross, MQI etc., in relation to poster and cell drop campaigns. This work will include discussion relating to the message, the timing of the message and agreeing the most effective medium to be used to deliver the message | Care & Rehabilitation | 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 | |
| 11/07/2024 | 11/03/2020 | Wheatfield Prison | Post-Incident Response | 2020C2 | Death in Custody | The Irish Prison Service should ensure that all staff who are not directly involved in operational or first aid efforts during a medical or other emergency return to their own posts as soon as it is practical. [Repeated Recommendation – see Mr. N 2012]. | Accepted | 12/04/2024 | Staff who are not directly involved in operational or first aid efforts during a medical or other emergency are instructed to return to their own posts as soon as it is practical. | Operations | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 11/07/2024 | 11/03/2020 | Wheatfield Prison | Family Contact | Record keeping | 2020C3 | Death in Custody | Incorrect NoK contact details can cause delays in establishing contact with the families in the case of emergencies. It is recommended that IPS staff verify the nominated NoK at committal by ringing the phone number provided. | Accepted | 12/04/2024 | The Prisons' Leadership Team has established a working group to review the IPS Death in Custody protocols. The maintenance of emergency contacts will be considered as part of this review. | Operations | 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 | |
| 22/09/2022 | 02/04/2020 | Mountjoy Men's Prison | Temporary Release | 2020D1 | Temporary Release | When Full Temporary Release is granted under the supervision of the Probation Service, the IPS must ensure Probation are informed of the date prior to release. | Accepted | 07/07/2022 | The Irish Prison Service and the Probation Service have a long established protocol in place to manage the release of prisoners with post release supervision orders. This protocol places a requirement on the Probation Service to complete risk assessments in a timely manner and on the Irish Prison Service to notify the Probation Service on the likelihood of a prisoner being released early. In addition, SOP No. 11-008 - Temporary Release RTR, FTR, Date to Date and AM – PM contains a checklist which should be completed prior to a prisoner being released. One of the items on the checklist includes a requirement to check if the Probation Service have been notified of an imminent release. Operations Directorate will issue a reminder to all staff regarding their obligations to notify the Probation Service of the release date of a prisoner. SOP No 11 – 008 – Temporary Release RTR will be included in the reminder. | Operations Directorate | Q2 2022 | NA | NA | NA | 28/04/2023 | IPS - Complete | Circular 05/23 was issued on 21/03/23 with SOP attached: “where a prisoner is subject to supervision by the Probation Service and has been approved temporary release or is being released on expiration of their sentence, the Senior Probation Officer in your prison should be notified” | NA | NA | NA | NA | NA | NA | |||||
| 22/09/2022 | 02/04/2020 | Mountjoy Men's Prison | Temporary Release | 2020D2 | Temporary Release | Where a person is on Temporary Release and under the Supervision of the Probation Service, the Irish Prison Service must advise the Probation Service when a death occurs of the person on release. | Accepted | 07/07/2022 | As the prisoner is under their supervision in the community, Probation Service may be the first to become aware of the death of a prisoner. The Irish Prison Service will notify Probation Service if they become aware of the death of a person on release. Operations Directorate will issue a reminder to staff to ensure Probation Service are notified where a death occurs of the person on release. | Operations Directorate | Q2 2022 | NA | NA | NA | 28/04/2023 | IPS - Complete | Note issued to all Operational Decision makers to remind them of the necessity to advise Probation Service of a Death of a prisoner while on TR and under the supervision of Probation 26/04/23. | NA | NA | NA | NA | NA | NA | |||||
| 22/09/2022 | 02/04/2020 | Mountjoy Men's Prison | Temporary Release | Community support | 2020D3 | Temporary Release | All appointments should be in place prior to the release of a prisoner on Temporary Release and not left to the person to make appointments. | Accepted | 07/07/2022 | The Irish Prison Service and the Probation Service have a long established protocol in place to manage the release of prisoners with post release supervision orders. This protocol places a requirement on the Probation Service to complete risk assessments in a timely manner and on the Irish Prison Service to notify the Probation Service on the likelihood of a prisoner being released early. In addition, SOP No. 11-008 - Temporary Release RTR, FTR, Date to Date and AM – PM contains a checklist which should be completed prior to a prisoner being released. One of the items on the checklist includes a requirement to check if the Probation Service have been notified of an imminent release. Operations Directorate will issue a reminder to all staff regarding their obligations to notify the Probation Service of the release date of a prisoner. SOP No 11 – 008 – Temporary Release RTR will be included in the reminder. | Operations Directorate | Q2 2022 | NA | NA | NA | 28/04/2023 | IPS - Complete | The issuing of Circular 05/23 where Probation are notified of TR should ensure that appointments are in place. | NA | NA | NA | NA | NA | NA | ||||
| 23/02/2023 | 10/04/2020 | Arbour Hill Prison | Healthcare | Equipment | 20200 | Death in Custody | The Irish Prison Service should conduct a review of the prison estate to determine a policy for the ratio of emergency first aid trained staff on duty to prisoners, and the availability of defibrillators in addition to those held by health care staff in the ‘Red Bag.’ | Not accepted | 03/08/2022 | The Irish Prison Service has healthcare staff on duty in all closed prisons on a 24 hour basis. These qualified healthcare staff provide the first response/pre-hospital emergency care to prisoners. Defibrillators are a part of the core emergency equipment in all prisons and in Q1 2022 a full review and replacement with the latest defibrillator equipment was undertaken. | Healthcare Directorate | Completed | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 23/02/2023 | 10/04/2020 | Arbour Hill Prison | Healthcare | Equipment | 202000 | Death in Custody | The Irish Prison Service should explore the viability of providing ‘chest compression machines’ to assist staff who are administering CPR. | Not accepted | 03/08/2022 | The Irish Prison service is working with colleagues in the National Ambulance Service to assess and evaluate the likely benefits of a “chest compression system” within the Irish Prison Service. It is anticipated this will be completed by Q4 2022. | Healthcare Directorate | Q4 2022 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | IPS in Process of acquiring up to 5 machines for deployment in specific sites around the estate incl Castlerea, Arbour Hill and Cloverhill . | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 23/02/2023 | 10/04/2020 | Arbour Hill Prison | Post-Incident Response | 2020000 | Death in Custody | The Irish Prison Service should examine the policy for responding to medical emergencies and consider the issues raised by prison staff during the critical incident review. | Partly accepted | 03/08/2022 | In response to staff recommendations: (i) Chest compression system Response – As per recommendation 2 above (ii) Privacy screens Response – Screen are available in each prison (iii) CPR training for officers Response – As per recommendation 1. (iv) Developing a checklist Response – this recommendation requires further clarification and discussion. Emergency response need to be managed and directed based on clinical assessment and appropriateness. (v) Radios enabled to make call to emergency services Response - The proposed action of enabling radios to contact other emergency services is not viable. The Irish Prison Service has an internal radio communications system that has capability for 24/7 contact with the on-site prison console. That console has telephony capability for contacting emergency services. All prison healthcare suites have external telephony as do Chiefs and ACO offices etc. This is the operating model the Irish Prison Service has always used and has always been successful. | Healthcare Directorate Operations Directorate | Ongoing | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | In addition to the initial action plan response,Prison management in conjunction with BSD are considering plans and prototypes for the installation of privacy screens and a further update will be provided in due course. An ongoing review of the cell call system infrastructure is exploring the option of emergency calls being placed from cells. | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||
| 23/02/2023 | 10/04/2020 | Arbour Hill Prison | Post-Incident Response | 20200000 | Death in Custody | Critical incident reviews must follow the guidance of the Irish Prison Service agreed protocol. | Accepted | 03/08/2022 | Operations will re-issue the 11 026 Critical Incident Reporting and Debrief Procedures SOP (1) drawing particular attention to the timeline of the debrief. | Operations Directorate | Q4 2022 | Q2 2024 | IPS - Complete | Staff debriefed on SOP. | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 24/02/2023 | 14/07/2020 | Castlerea Prison | Healthcare | Staffing | 2020G1 | Death in Custody | The Irish Prison Service should review the availability of a doctor for unexpected emergencies at Castlerea Prison. A similar recommendation was also made in relation to the death of Mr. N/2015 (pg. 8). | Not accepted | 05/07/2022 | The Irish Prison Service provides a 9-5 Monday to Friday GP service at Castlerea Prison and outside these hours an on call service is available. Out of hours emergencies are managed by nursing staff and the National Ambulance Service as required | Healthcare Directorate | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 24/02/2023 | 14/07/2020 | Castlerea Prison | Healthcare | Equipment | 2020G2 | Death in Custody | The Irish Prison Service should explore the viability of providing ‘chest compression machines’ to assist staff who are administering CPR. (Castlerea Prison is in a remote location and in this case arrival of paramedics took over 25 minutes from the time of being called. There are limited numbers trained on CPR in any prison). | Accepted | 05/07/2022 | Staff are trained to provide CPR and if required the National Ambulance Service will be called. Previously, the IPS contacted the medical Director of the NAS on the use of chest compression devices and the advice was that, as a priority, Irish Prison Service should support staff in maintaining their competence to provide CPR in response to medical emergencies. The Irish Prison service is working with colleagues in the National Ambulance Service to assess and evaluate the likely benefits of a “chest compression system” within the Irish Prison Service. It is anticipated this will be completed by Q4 2022. | Healthcare Directorate | Ongoing | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | IPS in Process of acquiring up to 5 machines for deployment in specific sites around the estate incl Castlerea, Arbour Hill and Cloverhill. | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 24/02/2023 | 14/07/2020 | Castlerea Prison | Post-Incident Response | Emergency response | 2020G3 | Death in Custody | The Irish Prison Service should examine emergency access to all cells, such as a ‘code red’ alert, to minimise the amount of time between a request for first aid or assistance and entry being made. Each prison should have a protocol in place aimed at reducing emergency access times to a cell to 4 minutes or below. If it is identified that access to a cell in an emergency is beyond 4 minutes, measures should be put in place to rectify this. | Not accepted | 05/07/2022 | To satisfy this recommendation, the Irish Prison Service would have to move away from the established practice of operating from a central key repository and establish secondary key repositories across many prisons. It is likely the response times in other prisons that are of the Pentonville design (Mountjoy, Midlands, Cloverhill etc.) would have much shorter response times. Castlerea Prison is a converted mental health facility that does not benefit from the efficiencies of such bespoke prison design. As keys are accounted for multiple times daily, the changing of practice would present serious challenges for all prison personnel involved in the process. Key security is essential in all prisons. | Operations Directorate | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 24/02/2023 | 14/07/2020 | Castlerea Prison | Post-Incident Response | Emergency response | 2020G4 | Death in Custody | Prison Governors should include oversight and effectiveness of emergency access to cells during their routine inspections of a prison | Recommendation in place | 05/07/2022 | This is part of the daily duties of the Governor, Chief Officer or Assistant Chief Officer as set out in Rule 76 of the Prison Rules, Delegation of functions. | Operations Directorate | Completed | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 31/05/2024 | 19/07/2020 | Limerick Prison | Safety | Policy review | 2020I-1 | Death in Custody | In cases where it is suspected that a prisoner may be concealing drugs, a thorough search of the cell in which they are accommodated should be conducted without delay. This search should be fully documented and information regarding the nature of any drugs found should be communicated to the prison’s healthcare team. This requirement should be set out in an Irish Prison Service Standard Operating Procedure (SOP). | Accepted | 23/05/2024 | A national SOP will be drafted as soon as possible to support prisons in cases where a prisoner is removed from his/her cell following a suspected overdose. Documented cell searches will be required under the SOP. The SOP will also consider operational and/or accommodation issues which may impact decision making and actions taken, as well as outlining requirements for communication with healthcare. | 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 | |
| 31/05/2024 | 19/07/2020 | Limerick Prison | Healthcare | Policy review | 2020I-2 | Death in Custody | If it is suspected that a prisoner may be concealing drugs internally (for example, if they continue to display signs of intoxication but 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 Directorate | 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 | |
| 31/05/2024 | 19/07/2020 | Limerick Prison | Safety | 2020I-3 | 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 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. | Partially Acepted | 23/05/2024 | See response to recommendation 2. | Operations & Care and Rehabilitation Directorate | 45444 | 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 | ||
| 31/05/2024 | 19/07/2020 | Limerick Prison | Healthcare | 2020I-4 | 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. The group has met with European colleagues and further discussions are planned. | Operations/Care and Rehabilitation/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 | ||
| 31/05/2024 | 19/07/2020 | Limerick Prison | Healthcare | 2020I-5 | Death in Custody | The Irish Prison Service should introduce a health care focused policy to respond to the threats and safety risks posed by the internal secretion 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 health care professionals in decision making regarding the supervision and care of a person where there is a suspicion of internal secretion of drugs and other items of contraband. All such decisions should include a recorded risk assessment. | Accepted | 23/05/2024 | See response to recommendation 2. | Care and Rehabilitation Directorate | 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 | ||
| 31/05/2024 | 19/07/2020 | Limerick Prison | Safety | Narcotics Detection | 2020I-6 | Death in Custody | 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. | Accepted | 23/05/2024 | 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 including commitments to work strategically and collaboratively with An Garda Síochána, addiction and other services to reduce the demand and supply of drugs in the prison environment. Security reviews have been carried out in all closed prisons over the past 24 months and a number of recommendations to restrict the flow of contraband have been made. OSG are also 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 and OSG continue to lead in this area for IPS. | Operations Directorate | 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 | |
| 31/05/2024 | 19/07/2020 | Limerick Prison | Safety | Narcotics Detection | 2020I-7 | Death in Custody | The IPS 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. | Accepted | 23/05/2024 | 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 including commitments to work strategically and collaboratively with An Garda Síochána, addiction and other services to reduce the demand and supply of drugs in the prison environment. A group has been established comprising of representatives from both the Irish Prison Service and An Garda Siochana. The first meeting of the group convened on 10th April, the group will meet biannually and have committed to further collaboration on sharing intelligence, strategic planning of joint operations on throw overs, and support in enhancing current infrastructure, e.g. anti-drone technology. Irish Prison Service engagement with An Garda Siochana has resulted in a number of successful operations, for example at Wheatfield/Cloverhill complex there were 75 arrests during the period 20/02/2023 – 16/03/2024. These operations are dependent on An Garda Siochana resources being available. Research into equipment suitable for use in a prison environment is ongoing. OSG continue to carry out random and intelligence led searches to detect and deter contraband entry. Engagement with local An Garda Siochana liaisons is ongoing in this regard. | Operations Directorate | 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 | |
| 13/02/2026 | 28/09/2020 | Cloverhill Prison | Policy and Procedures | Training | 2020J1 | Death in Custody | The IPS should review its control and restraint training programme to ensure that all officers called upon to perform restraint duties remain fully trained in the techniques and are aware of the risks and dangers associated with C&R. In particular, all prison officers called upon to engage in the restraint of prisoners should receive ongoing awareness training on the risks of positional asphyxia and excited delirium associated with the use of C&R | Accepted - Already in Place | The Irish Prison Service is satisfied that the current control and restraint programme is sufficient and that officers called upon to perform C&R are trained and aware of the risks associated with C&R. The current training programme is currently a one-day programme with four hours dedicated to C&R. Within this programme positional asphyxia, excited delirium, psychosis and sickle cell disease are all addressed. In addition, the Control and Restraint manual was reviewed and updated in 2023 by an expert internal group led by the Governor 1 Operations. | Operations Directorate | N/A | |||||||||||||||||
| 13/02/2026 | 28/09/2020 | Cloverhill Prison | Policy and Procedures | Training | 2020J2 | Death in Custody | To be certified as competent in C&R, an officer should pass a technical and written examination to ensure officers performing C&R techniques fully understand the dangers in restraining prisoners in the prone position and the importance of seeking healthcare advice when considering restraining prisoners with physical and/or mental illness. | Not Accepted | During CPD training, C&R Instructors deliver training and monitor staff throughout a four-hour C&R basic refresher in which they observe staff demonstrating these techniques before moving through the syllabus. Basic C&R refresher modules are physical participation modules and at this time, we do not believe that a written/technical examination would be an addition as it could take from the limited time available for these modules. It could also potentially reduce the limited time available for other forms of CPD and training, which has to be provided over the course of a year. The revised C&R manual also covers the dangers of restraining prisoners in a prone position. During all planned relocations, the C&R supervisor will seek healthcare advice. This is one of their responsibilities as outlined in the C&R manual. | Operations Directorate | N/A | |||||||||||||||||
| 13/02/2026 | 28/09/2020 | Cloverhill Prison | Policy and Procedures | Mental Health | 2020J3 | Death in Custody | Where a prisoner with a mental health illness is non-cooperative, the advice of healthcare staff should be sought, if possible, before C&R techniques are applied. However, if a prisoner has a recognised mental health illness and/or has PICLS oversight, that prisoner should be risk assessed for any potential moves which may necessitate C & R. | Partially Acepted | Medical staff should always be contacted prior to a planned C&R removal. However, an additional risk assessment has the potential to delay a C&R removal and increase the level of risk to both staff and prisoners. It should be noted that every year, C&R trained staff move and relocate hundreds of prisoners using C&R techniques some of whom have mental health issue/illness without any detrimental effect on the prisoner being moved | Care & Rehabilitation/Operations | N/A | |||||||||||||||||
| 13/02/2026 | 28/09/2020 | Cloverhill Prison | CCTV | 2020J4 | Death in Custody | The IPS should accelerate its programme of upgrading CCTV in Irish prisons, with a view to eradicating remaining “blind spots” in the coverage of communal areas, including stairwells. | Accepted - Already in Place | Significant investment has taken place over the past number of years upgrading the CCTV system for the Irish Prison Service estate. Since 2014, over €6m has been invested in the CCTV systems and this investment will continue over the coming years. Placement of CCTV cameras will be determined in line with the scope and location of these works. | Operations Directorate / Estates | Complete | ||||||||||||||||||
| 13/02/2026 | 28/09/2020 | Cloverhill Prison | Standard Operating Procedures | 2020J5 | Death in Custody | Before chairing Critical Incident Review Meetings, Governors should seek to establish the basic facts regarding the incidents concerned, in order that they can highlight any shortcomings that need to be addressed as well as commending any good practices identified. | Accepted - Already in Place | The Governor I Prison Support and Development has reviewed the template with relevant stakeholders and a standard template has been developed to support the structure of critical incident meetings and the gathering of relevant information. | Operations Directorate / Corporate Services | Complete | ||||||||||||||||||
| 12/09/2025 | 15/11/2020 | Limerick Prison | Safety | Narcotics Detection | 2020L1 | Death in Custody | In cases where it is suspected that a prisoner may be concealing drugs internally (for example, if they continue to display signs of intoxication but 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. A similar recommendation was made in the Inspectorate’s report on the death in custody of Mr. I 2020 and accepted by the IPS | Accepted | Procedures for the care and management of prisoners suspected of internally concealing any prohibited article or substance 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 Directorate | Complete | |||||||||||||||||
| 12/09/2025 | 15/11/2020 | Limerick Prison | Safety | Narcotics Detection | 2020L2 | 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 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 made in the Mr. I 2020 report and was 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 & Rehabiliation/Operations Directorate | Ongoing | |||||||||||||||||
| 12/09/2025 | 15/11/2020 | Limerick Prison | Safety | Narcotics Detection | 2020L3 | Death in Custody | There is no systematic justification or rationale for the routine placement of prisoners in refractory clothing, irrespective of whether they are accommodated in a SOC or a CSC cell. Such a measure could only be justified if a prisoner placed in a SOC is considered to be at risk of suicide, and it should not applied if a prisoner is placed in a CSC for security reasons. The Inspectorate recommends that this practice be brought to an immediate end. 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 & Rehabiliaton/Operations Directorate | Complete | |||||||||||||||||
| 12/09/2025 | 15/11/2020 | Limerick Prison | Healthcare | 2020L4 | Death in Custody | 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. This recommendation was made in the Mr. I 2020 report and was 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 & Rehabiliation Directorate | Ongoing | ||||||||||||||||||
| 12/09/2025 | 15/11/2020 | Limerick Prison | Policy | Healthcare | 2020L5 | Death in Custody | he 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 the Mr. I 2020 report and was 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 Directorate | Complete | |||||||||||||||||
| 12/09/2025 | 15/11/2020 | Limerick Prison | Safety | Narcotics Detection | 2020L6 | Death in Custody | 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 made in the Mr. I 2020 report and was accepted by the IPS. | Accepted - Already in Place | Accepted - Already in Place | Operations | Complete | |||||||||||||||||
| 12/09/2025 | 15/11/2020 | Limerick Prison | Safety | Narcotics Detection | 2020L7 | Death in Custody | 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 Mr. I 2020 report and was accepted by the IPS. | Accepted - Already in Place | See recommendations no. 4 and 6 above. | Operations | Complete | |||||||||||||||||
| 14/08/2025 | 16/12/2020 | Castlerea Prison | Temporary Release | Record Keeping | 2020M1 | Temporary Release | Prisoners who are granted RTR and are required to engage with community services that are only available on weekdays should only be released between Monday and Thursday. | Not accepted | Relevant staff have been reminded that, in line with the Prisoner release planning policy, applications for reviewable temporary release, where the release would take place on a Friday should not be submitted or approved subject to operational constraints. It should however be noted that IPS are experiencing extreme levels of overcrowding and, while the preferred option is to release MonThursday, releases on Fridays may increase in order to ensure the safety and security of our prisons | Operations Directorate | Complete | |||||||||||||||||
| 14/08/2025 | 16/12/2020 | Castlerea Prison | Temporary Release | Record Keeping | 2020M2 | Temporary Release | Where a RTR plan has been approved, this should not be varied unless all relevant parties have been contacted and details as to who was contacted and when (time and date) recorded on Prisoner Information Management System (PIMS). This requirement should be included in the IPS Temporary Release Policy Guidance. | Accepted | The IPS will reflect this recommendation in its next review of the "Temporary Release RTR, FTR, Date to Date and AM – PM" SOP. | Operations Directorate | Q12025 | |||||||||||||||||
| 14/08/2025 | 16/12/2020 | Castlerea Prison | Temporary Release | Record keeping | 2020M3 | Temporary Release | The basis for all decisions relating to a temporary release should be accurately recorded on PIMS. | Accepted | The IPS will reflect this recommendation in its next review of the "Temporary Release RTR, FTR, Date to Date and AM – PM" SOP. | Operations Directorate | Q12025 | |||||||||||||||||
| 14/08/2025 | 16/12/2020 | Castlerea Prison | Policy & Procedure | Record keeping | 2020M4 | Temporary Release | The IPS should review its record keeping policy in order to improve accountability and ensure the accurate recording of operational and medical activities. | Accepted | The IPS Strategy 2023-2027 outlines the IPS' intention to digitise prison record keeping and also to roll out self audits to have better internal review processes in place and narrow the margin for human error. The IPS' ability to deliver on its strategic objectives is dependent on the availability of resources, particularly in the context of overcrowding. | Corporate Services Directorate | Ongoing | |||||||||||||||||
| 30/05/02023 | 15/01/2022 | Cork Prison | Family Contact | Calls | 2022C6 | Death in Custody | The Irish Prison Service should, in accordance with Rule 46(4)(a) ensure that a remand prisoner is permitted to make not less than five phone calls per week and if any of these calls fail, the reason should be recorded. | Accepted | 17/05/2023 | The current prisoner phone systems allows remand prisoners to make not less than 5 calls per week. ICT and Operations are examining if a technical solution can be put in place to record the reasons a call may fail. They are also examining if functionality could be added to recognise the numerical amount of numbers entered for a phone number and issue a prompt if under or over the correct amount. | Operations Directorate | Q4 2023 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | Q2 2024 | IPS - Ongoing | The current prisoner phone systems allows remand prisoners to make not less than 5 calls per week. ICT and Operations are examining if a technical solution can be put in . | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 30/05/02023 | 15/01/2022 | Cork Prison | Record-Keeping | Property | 2022C7 | Death in Custody | It is recommended that an inventory of all clothing and other personal items in the possession of a person on committal should be recorded in accordance with Rule 8(1) of the Prison Rules 2007-2020, this inventory should include clothing and its label. In addition, a similar inventory should be made of all items returned to the family/next-of-kin following a death in custody and separately a list should be compiled by prison staff of any item(s) taken in to the possession of An Garda Síochána. | Accepted | 17/05/2023 | Management of prisoner property, including the signing out of property where a prisoner is deceased, is covered in the Prisoner Property Policy. All property is recorded on PIMS including whom the property is checked out to. Operations Directorate will reissue this Circular and will reiterate to prison staff their obligations and responsibilities regarding same. | Operations Directorate | Q2 2023 | Q2 2024 | IPS - Complete | Property recorded as per policy. | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 08/08/2024 | 27/04/2021 | Cloverhill Prison | Policy & Procedure | 2021C1 | Death in Custody | The Irish Prison Service should introduce a health care focused policy to respond to the threats and safety risks posed by the internal secretion of drugs and other items of contraband. This policy should clarify the roles and responsibilities of management, prison officers, and healthcare staff. | Accepted | 12/04/2024 | The Irish Prison Service is working on an SOP to manage prisoners who are suspected to have drugs/contraband secreted internally to ensure that they are monitored appropriately from both a healthcare and operational point of view. The SOP will aim to provide clear guidance to both healthcare staff, prison officers and prison management. It is hoped that this SOP will be in place by the end of Q3 of this year, subject to engagement with relevant stakeholders | Care & Rehabilitation / Operations | 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 | ||
| 08/08/2024 | 27/04/2021 | Cloverhill Prison | Healthcare | 2021C2 | Death in Custody | This new policy should provide for a central role for health care professionals in decision making regarding the supervision and care of a person where there is a suspicion of internal secretion of drugs and other items of contraband. All such decisions should include a recorded risk assessment. | Accepted | 12/04/2024 | The SOP referenced above will provide for a central role for healthcare professionals in the assessment and subsequent management of prisoners who are suspected of secreting drugs/contraband to ensure that the appropriate level of care and supervision is provided for such prisoners. | Care & Rehabilitation / Operations | 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 | ||
| 08/08/2024 | 27/04/2021 | Cloverhill Prison | Healthcare | Policy & Procedure | 2021C3 | 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 isolated in a Safety Observation Cell (SOC) under medical supervision, not in a Close Supervision Cell (CSC) under security observation. | Not Accepted | 12/04/2024 | It is imperative that SOCs are reserved for use only in exceptional cases for prisoners who are psychiatrically unwell and represent a clear risk to themselves and/or others as a result of severe psychiatric illness or psychological disturbance. Prisoners who are suspected of secreting drugs/contraband internally will continue to be accommodated in a CSC, however, with the addition of healthcare monitoring as provided for in the revised CSC SOP and/or healthcare SOP as referenced above. | Care & Rehabilitation / Operations | 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 | |
| 08/08/2024 | 27/04/2021 | Cloverhill Prison | Safety | Policy & Procedure | 2021C4 | Death in Custody | The Irish Prison Service should intensify its efforts to physically prevent contraband from entering the prisons and to detect its presence once on the premises, including through technological means. | Accepted | 12/04/2024 | 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 including commitments to work strategically and collaboratively with An Garda Síochána, addiction and other services to reduce the demand and supply of drugs in the prison environment. A group has been established comprising of representatives from both the Irish Prison Service and An Garda Siochana. The first meeting of the group convened on 10th April, the group will meet biannually and have committed to further collaboration on sharing intelligence, strategic planning of joint operations on throw overs, and support in enhancing current infrastructure, e.g. anti-drone technology. Irish Prison Service engagement with An Garda Siochana has resulted in a number of successful operations, for example at Wheatfield/Cloverhill complex there were 75 arrests during the period 20/02/2023 – 16/03/2024. These operations are dependent on An Garda Siochana resources being available. Research into equipment suitable for use in a prison environment is ongoing. OSG continue to carry out random and intelligence led searches to detect and deter contraband entry. Engagement with local An Garda Siochana liaisons is ongoing in this regard. | Operations | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 08/08/2024 | 27/04/2021 | Cloverhill Prison | Safety | Policy & Procedure | 2021C5 | Death in Custody | The Irish Prison Service should intensify its engagement with other relevant stakeholders, including An Garda Síochána, to develop a multi-agency written 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 bring drugs and other contraband into a prison. | Accepted | 12/04/2024 | See recommendation 4 [ 2021C4] | Operations | 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 | |
| 20/08/2024 | 12/08/2021 | Cloverhill Prison | Safety | Narcotics Detection | 2021-E1 | Death in Custody | The Irish Prison Service should intensify its efforts to physically prevent contraband from entering the prisons and to detect its presence once on the premises, including through technological means. | Accepted | 12/04/2024 | The Irish Prison Service published its new Drugs Strategy 2023‐2026 in November 2023. This comprehensive strategy outlines a series of goals aimed at reducing the harm caused by substance abuse within the prison environment, and acknowledges the need for strong, consistent inter‐agency collaboration. The new drugs strategy provides practical measures to be implemented and digital innovations to be explored by the Irish Prison Service in addressing the issue of illicit drug use over the next three years. | Operations | 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 | |
| 20/08/2024 | 12/08/2021 | Cloverhill Prison | Safety | Narcotics Detection | 2021-E2 | Death in Custody | The Irish Prison Service should intensify its engagement with other relevant stakeholder including An Garda Síochána, to develop a multi‐agency written 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 bring drugs and other contraband into a prison. | Accepted | 12/04/2024 | 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 including commitments to work strategically and collaboratively with An Garda Síochána, addiction and other services to reduce the demand and supply of drugs in the prison environment. A group has been established comprising of representatives from both the Irish Prison Service and An Garda Siochana. The first meeting of the group convened on 10th April, the group will meet biannually and have committed to further collaboration on sharing intelligence, strategic planning of joint operations on throw overs, and support in enhancing current infrastructure, e.g. anti‐drone technology. Irish Prison Service engagement with An Garda Siochana has resulted in a number of successful operations, for example at Wheatfield/Cloverhill complex there were 75 arrests during the period 20/02/2023 – 16/03/2024. These operations are dependent on An Garda Siochana resources being available. | Operations | 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 | |
| 24/01/2024 | 02/10/2021 | Cork Prison | Accomodation | Safety | 2021G1 | Death in Custody | The Irish Prison Service should ensure that the ‘volume control’ on all emergency activation devices in the Class Office and Control Room across the prison estate be locked to an audible volume which cannot be lowered or deactivated. | Accepted | 20/09/2023 | The Director General of the Irish Prison wrote to all lead Governors requesting confirmation that each cell call bell is working and turned to the appropriate volume level in each of the class offices. Confirmation was received from all lead Governors. The Irish Prison Service will undertake an external audit of the cell call system nationally in the coming months. | Estates 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 | |
| 24/01/2024 | 02/10/2021 | Cork Prison | Policy & Procedure | 2021G2 | Death in Custody | A Class Officer and an Assistant Class Officer should continuously observe the landing to which they are detailed to, inter alia, ensure prisoners are adequately supervised to ensure they do not require urgent attention. | Not Accepted | 20/09/2023 | In 2019 the Irish Prison Service carried out a review of the policy and Standard Operating Procedures with regard to the Monitoring of Prisoners during Periods of Lock Up.The revised documents were published on the IPS Intranet and a comprehensive communications plan was rolled out to raise awareness of same.These Standing Operating Procedures were designed to ensure that prisoners are adequately supervised, they were constructed based on experience and risk assessment while considering the needs of the 2007 Prison Rules. | Operations | Already in place. | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 24/01/2024 | 02/10/2021 | Cork Prison | Accomodation | Safety | 2021G3 | Death in Custody | Class Officers and management grades should ensure that the visibility of a landing is not obstructed by posters and/or notices displaced on the glass panel of a Class Office. It is recommended that Irish Prison Service HQ issue an instruction to this effect to all Prison Governors who should ensure implementation and compliance. | Accepted | 20/09/2023 | Governor I Prison Support and Development has written to all Lead Governors advising them of the requirement to leave visibility from Class Offices unobstructed. | Corporate Services Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 24/01/2024 | 02/10/2021 | Cork Prison | Accomodation | Safety | 2021G4 | Death in Custody | The Irish Prison Service consider the relocation of the Cell Call Activation light from its current position and place it towards the top of the cell door thereby eliminating any possible obstruction of a flashing light. | Accepted | 20/09/2023 | The Irish Prison Service are currently developing a cell call monitor module which will be located in the nearby class office. This module will have an integrated light indicator for each cell to add a further enhance vision aid to the Officer. Due to its bespoke design, combined with the necessary testing and development, the sample unit is planned to be available by the end of 2023 | Estates Directorates | Q4 2023 | 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 | |
| 24/01/2024 | 02/10/2021 | Cork Prison | Next of Kin | Policy review | 2021G5 | Death in Custody | Consideration should be given to a review of the ‘Chaplaincy and Next of Kin Notification’ document to include guidance on the provision of general practical information to the NoK following a death in custody. | Accepted | 20/09/2023 | The Irish Prison Service will review the “Next of Kin Notification Protocol”. | Care and Rehabilitation | Q4 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 | |
| 24/01/2024 | 02/10/2021 | Cork Prison | Policy review | Debriefing Procedures | 2021G6 | Death in Custody | It is recommended that that an Office Notice be issued to all Prison Governors to remind them of the importance of adherence to the terms of the IPS ‘Critical Incident Reporting and Debriefing Procedures’ which provides for the holding of both a hot and cold debrief following a death in custody and for all staff involved in the incident to be encouraged/facilitated to attend briefing. | Accepted | 20/09/2023 | Circular 08/2023 issued in June 2023 reminding all staff of the Critical Incident Reporting and Debrief SOP. It further instructed that the SOP should be read in conjunction with Operations circular 11/2016 – Reporting of serious and critical incidents (Rule 83) which is also contained in Appendix 1 of the document. The Irish Prison Service have committed to conducting a review of all relevant SOP’s/circulars relating to critical incident reporting in the coming months. | Operations | End Q4 2023 | 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 | |
| 24/01/2024 | 02/10/2021 | Cork Prison | Record Keeping | 2021G7 | Death in Custody | 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 recommendation has been made in the past in Mr A 2012, Mr H 2014 and Mr I 2018. | Accepted | 20/09/2023 | The importance of accurate record keeping is covered during Recruit Prison Officer training and compliance is overseen at governor level. The Irish Prison Service are in the late stages of a prison security audit and discrepancies in record keeping will be brought to the attention of Senior Management with recommendations attached, this report is due in Q3 2023. Relevant officials have been identified to examine how the Irish Prison Service can streamline and improve the information management process in relation to logbooks and journals. The IPS intends to replace manual or written log books with the electronic recording of information. An IT solution is being explored to facilitate a more effective and efficient logging process which will support accuracy. Governor I Prison Support and Development will advise all Lead Governors of their obligations under Rule 75 and related SOPs (available to all staff on PRISM) to ensure staff are creating accurate records/reports of their duty at the next meeting of the Prisons’ Leadership Team. | Operations & Corporate Services Directorate | Update Q4 2023 | 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 | ||
| 24/01/2024 | 02/10/2021 | Cork Prison | Safety | Policy Review | 2021G8 | Death in Custody | 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. | Accepted | 20/09/2023 | Governor I Prison Support and Development has written to all Lead Governors requesting that all staff be reminded of their obligations under Prison Rule 87(1)(b). | Corporate Services Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 21/08/2024 | 16/11/2021 | Midlands Prison | Policy Review | Compassionate Temporary Release | 2021H-1 | Death in Custody | The OIP recommends that the IPS take all necessary steps to ensure that any future recommendations from prison doctors regarding CTR are more promptly processed including, if required, by being formally transmitted to the Department of Justice for a decision. In all circumstances in which a prison doctor advises a Governor in writing that Rule 105 (a) or (b) of the prison Rules applies, expeditious efforts should be made by the Governor, the IPS and/or the Department of Justice to arrange for the compassionate release of the prisoner concerned. | Accepted | 12/04/2024 | The Irish Prison Service processes all recommendations from prison doctors under Rule 105 as priority, escalating the decision using the e-submissions platform to the Department of Justice and Minster as necessary to the individual circumstances. | Operations | Complete | ||||||||||||||||
| 02/02/2024 | 08/12/2021 | CCJ | Policy & Procedure | Healthcare | 2021X1 | Death in Custody | A ‘Person Escort Record’ should be introduced and completed for every movement of a person into or out of prison custody whether by Irish Prison Service staff or by members of An Garda Síochána. This should include details of all medication; when each item is prescribed to be administered; risk of self-harm and vulnerability in addition to security considerations. It should also include any significant comments or threats made by a detained person in connection with their safety or the safety of others. (A similar recommendation was made in Death in Custody Report Ref Ms X 2019 and was accepted by the Irish Prison Service. An example of a Person Escort Record was provided as a footnote in Report Ref Ms X 2019 and is again provided at footnote 2 in this report). | Accepted | 14/07/2024 | Historically, An Garda Siochana provided information on a form known as a C63 form. This form contained details of background information on the prisoners convictions, habits and some health information. This form is still used and provided in certain prisons but its use is not widespread nor is there a formalised agreement between both organisations on same. In 2021, an information sharing group was established to look at information sharing between various Justice bodies, they have begun the process of looking at the sharing of risk relevant information including the C63 form. The Irish Prison Service will bring this recommendation to the attention of the Information sharing group for consideration. The Irish Prison Service and An Garda Siochana met in late April to discuss this issue and others. A review of the shared UAL Protocol has commenced, this review will take account of changes to the AGS operating model and identify up-to-date Garda Liaison Officers for each prison. As part of this review, consideration will be given to establishing new centralised reporting email structures between the two organisations, while the CJOH (Criminal Justice Information Hub) solution is forthcoming. | Operations Directorate | Ongoing | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 02/02/2024 | 08/12/2021 | CCJ | Policy & Procedure | Healthcare | 2021X2 | Death in Custody | As individuals are being placed in the temporary custody of the Irish Prison Service by An Garda Síochána for the purpose of their appearance in Court, the Irish Prison Service should assign a nurse to the Criminal Court of Justice to conduct a Nurses Committal Interview[1]. Where concerns come to light and/or where the person has to take medication at specific intervals and/or time, the nurse should make arrangements for a prison Doctor to prescribe the required medication to be administered by the Irish Prison Service nurse during their temporary custody. | Not Accepted | 14/07/2024 | Healthcare is provided to those in the Irish Prison Service at prison level. All committals undergo a committal assessment conducted by the Healthcare staff and covers a wide range of health issues .Medical care for persons in the custody of An Garda Siochana does not fall within the remit of the Irish Prison Service. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 02/02/2024 | 08/12/2021 | CCJ | Policy & Procedure | Record Keeping | 2021X3 | Death in Custody | The Irish Prison Service should introduce a ‘Personal Belongings Record’ to be completed by the Criminal Court of Justice Reception Officer. The written record should record all items of personal belongings, including medication taken into possession by the Irish Prison Service while the person is in their custody and where it is retained i.e. locker 7. The form should have provision for signatures when taking possession of personal belongings and when returning the belongings to include the time signed-out, who signed it out and to whom. The Record should be signed by the Reception Officer, the person being placed into custody and witnessed by a member of An Garda Síochána, if present. | Not Accepted | 14/07/2024 | Resources are not available to conduct this task at court level. It is suggested that all property in the possession of the person concerned be logged by An Garda Siochana and that log and property by provided to the Irish Prison Service for temporary storage. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 02/02/2024 | 08/12/2021 | CCJ | Policy & Procedure | Healthcare | 2021X4 | Death in Custody | A Standard Operating Procedure should be developed by the Irish Prison Service to provide Healthcare personnel with clear guidance when a person requiring immediate and/or ongoing healthcare attention is presented by An Garda Síochána to be placed into the temporary custody of the Irish Prison Service. | Not Accepted | 14/07/2024 | Persons in Garda custody requiring immediate and/or ongoing healthcare attention should receive appropriate medical care and not be lodged inappropriately into the temporary custody of the Irish Prison Service. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 05/11/2024 | 05/01/2022 | Mountjoy Prison | Policy & Procedure | Healthcare | 2022B-1 | Death in Custody | It is recommended that any prisoner who has been referred to an Emergency Department, or any hospital appointment, and who returns to prison without treatment be seen by the prison doctor as soon as possible following their return to the prison. | Accepted | 02/08/2024 | IPS Healthcare are currently developing an SOP which will require that prisoners who refuse treatment in hospital will be seen by the prison doctor as soon as possible following their return. | Care & Rehabilitation | Q4 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2024 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 05/11/2024 | 05/01/2022 | Mountjoy Prison | Policy & Procedure | Healthcare | 2022B-2 | Death in Custody | The IPS Director of Care an Rehabilitation should conduct a detailed review of the quality of the medical care provided to Mr B while in the custody of the Prison Service, with a view to establishing whether or not an earlier medical intervention in the prison and/or hospitalisation at an earlier stage might have saved his life. | Accepted | 02/08/2024 | An external resource will be appointed to conduct a detailed review of the medical care provided to Mr. B. | Care & Rehabilitation | Q4 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 | |
| 20/02/2026 | 04/02/2022 | Cloverhill Prison | Healthcare | Mental Health | 2022D1 | Death in Custody | This report on the death of Mr. D reinforces the findings and recommendations made by the OIP in its Thematic Inspection Report - An Evaluation of the Provision of Psychiatric Care in the Irish Prison System published on 20 February 2024. These include a recommendation that: “urgent consideration be given to the systemic changes that are required to facilitate the swift transfer of minor offenders who have mental disorders to local psychiatric hospitals. As this is likely to require the development and opening of long discussed, appropriately secure, intensive care facilities/designated beds in civil psychiatric hospitals, this calls for a multi-agency approach”. In its report on a full unannounced inspection of Cloverhill Prison in May 2023, the OIP also reiterated its previous (2021) recommendation to the Director General of the Irish Prison Service that persons detained in Cloverhill Prison who require mental health care must receive it an appropriate therapeutic environment. On 13 January 2025, the Chief Inspector of Prisons wrote to the Governor of Cloverhill Prison, after a follow-up inspection of Cloverhill Prison from 9 to 11 December 2024, indicating that the “situation on D2, which is housing a number of prisoner-patients who simply should not be in prison, remains critical. Mr D was committed to prison despite his history of mental illness and, in the short time he spent in custody before his death, he displayed clear symptoms of psychiatric disturbance, coupled with neglect of his personal hygiene. Notwithstanding the efforts of prison officers, health care staff and the PICLS team, D2 at Cloverhill Prison did not provide him with the therapeutic environment that he required. Urgent action is required to implement the OIP’s long-standing recommendations in relation to the care of people with mental disorders admitted to prison. | Accepted | 19/02/2026 | The Irish Prison Service fully recognises the particular vulnerabilities of people in custody who experience mental illness however, Irish prisons are not mental health facilities. The Irish Prison Service remains committed to ensuring that all individuals in our custody are treated with dignity, provided with appropriate healthcare, and managed in a manner that prioritises their safety and wellbeing. Healthcare in Irish prisons is delivered by the Irish Prison Service and we work in close partnership with the National Forensic Mental Health Service (NFMHS), the HSE, the Department of Justice, Home Affairs and Migration and other agencies to ensure that people with acute mental health needs receive appropriate assessment, treatment and, where required, transfer to designated centres.It was not determined that Mr. D required transfer to a psychiatric hospital. | Care and Rehablitation | Ongoing | ||||||||||||||||
| 20/02/2026 | 04/02/2022 | Cloverhill Prison | Healthcare | Prisoner Welfare | 2022D2 | Death in Custody | The OIP acknowledges the dedication of the prison staff who work in the very challenging conditions in D2 in Cloverhill Prison. Nonetheless, it is of concern that officers who noticed the deterioration in Mr. D’s physical wellbeing on 22 January 2022 did not report this incident to a doctor or nursing staff until the next day. It is recommended that any noticeable changes in the physical or mental status of a prisoner on the D2 landing be reported in real time to medical staff for immediate assessment. | Not Accepted | 19/02/2026 | The Irish Prison Service healthcare teams in each prison act on any report by an officer. Operational staff provide significant support to prison healthcare teams, but are not clinicians and cannot be expected to provide the same observations as a clinician. | Care and Rehabilitation | Ongoing | ||||||||||||||||
| 20/02/2026 | 04/02/2022 | Cloverhill Prison | Healthcare | 2022D3 | Death in Custody | While it is recognised that all checks, as per current standards, were conducted on Mr. D’s cell throughout the previous night, it is clear from the CNO’s decision not to commence CPR that Mr. D had been dead while some of these cell checks were conducted. 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. This was accepted as a recommendation in response to the OIP’s investigation report in the case of Mr. K 2024. | Accepted | 19/02/2026 | Tendering is currently live in Q1 2026 and Signs of Life technology will be piloted in Cloverhill and Limerick Prisons. | Care and Rehabilitation | Q42026 | |||||||||||||||||
| 20/02/2026 | 04/02/2022 | Cloverhill Prison | Healthcare | 2022D4 | Death in Custody | The Office of Inspector of Prisons endorses the observation submitted by Chief B in his report of 10 March 2022 in relation to the usefulness of a chest compression machines to assist with the delivery of CPR. This recommendation was previously made in the OIP’s report on its investigation into the death of Mr. E 2020 and the corresponding IPS Action plan confirmed, in its most recent update (Q2 2024), that the IPS was in the process of purchasing five machines. It is recommended that this process be finalised and that Cloverhill Prison be equipped with such a machine. | Accepted | 19/02/2026 | The prison estate has purchased five LUCAS machines which are currently being trialled on a pilot bases in a number of locations. There will be a review of availability and training of existing machines before a rollout to Cloverhill is considered. | Care and Rehabilitation | Ongoing | |||||||||||||||||
| 23/04/2025 | 03/05/2022 | Mountjoy | Policy & Procedure | NOK Contact | 2022H1 | Death in Custody | It is recommended that on committal or as soon as possible thereafter that contact be made with the nominated next-of-kin to obtain their consent to be recorded as NoK and ensure that the details provided are valid. | Not Accepted | IPS cannot accept this recommendation as this would impose an inordinate administrative burden on the organisation. In addition, this type of procedure would not be considered common practice across the public sector | Operations Directorate | Complete | |||||||||||||||||
| 23/04/2025 | 03/05/2022 | Mountjoy | Policy & Procdure | NOK Contact | 2022H2 | Death in Custody | It is recommended that the IPS put in place streamlined procedures to enable the nominated NoK of prisoners to easily update their contact details, for example, through the use of a dedicated email address for the IPS section with responsibility for updating PIMS prisoner details. | To be considered | On a regular basis, the Operations Directorate requests that Prison Governors conduct a census of prisoners’ next of kin details to ensure that they are up to date. This process is supported by IT reports made available to all prisons. Ops Circular 04/25 issued on 13 February 2025 refers. In addition, IPS are in the process of developing a formal Next of Kin policy which will take this recommendation into consideration | Operations & Care & Rehabilitation Directorates | Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q122025 | IPS UPDATE REQUIRED - ONGOING Q122025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | ||||||||||||||
| 22/08/2024 | 09/06/2022 | Midlands Prison | Safety | SOP | 2022K2 | Death in Custody | When conducting routine checks of cells, prison officers should be especially attentive to the presence of non-standard items, such as “hammock” type footrests, that could be deployed as ligatures. If detected, such items should be immediately confiscated and a clear written record kept of their confiscation, indicating the cell location and the name of the prisoner concerned | Partially Accepted | 07/06/2024 | Prisoners who are considered to pose a risk to themselves or who notify prison staff of any intention to self-harm are referred to appropriate services in the prison and may be placed on special monitoring.Where there is no indication of risk associated with a prisoner, and where their property has not been classified as prohibited under Rule 9 of the Prison Rules, there will not be a requirement for confiscation. | Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 22/08/2024 | 09/06/2022 | Midlands Prison | Policy & Procedure | 2022K3 | Death in Custody | In the interest of uniformity of procedure across all prisons it is recommended that Irish Prison Service Headquarters develop a centralised Standard Operating Procedure outlining the duties and responsibilities attaching to the role of Class Officer, including the need to maintain a written record on date and time of checks undertaken and outcomes. | Accepted | 07/06/2024 | The Irish Prison Service has confirmed a commitment to develop an Operations Manual as part of their Strategic Plan lifecycle. Work has commenced on certain Standard Operating Procedures to this end. Other areas will be prioritised as resources are allocated. | Operations, Risk, HR | 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 | ||
| 31/07/2025 | 10/08/2022 | Cloverhill Prison | Safety | Mental Health | 2022O3 | Death In Custody | 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 be brought to an immediate end. This Inspectorate recommendation is fully consistent with the views of the European Committee for the Prevention of Torture (CPT) on this subject. | Not Accepted | 27/06/2025 | 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. | Operationrs & Care and Rebabilitation Directorate | Closed | ||||||||||||||||
| 31/07/2025 | 10/08/2022 | Cloverhill Prison | Healthcare | 2022O4 | Death In Custody | In order to enhance the effectiveness of the health care monitoring, the Inspectorate recommends that the IPS explore the potential of employing remote monitoring of vital signs technology in prisons in Ireland. This recommendation was previously made and accepted in the report of Mr. K 2024, published in July 2024. The Director General committed to the establishment of a sub-group to examine this technology. The OIP is looking forward to receiving the findings of the sub-group. | Accepted - Already in Place | 27/06/2025 | A multi-disciplinary working group has been established to examine to possibilty of implementing signs of life technology.2 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. The Irish Prison Service is currently awaiting feedback from the CSSO regarding the legality of installing such technology in CSCs and SOCs. | Care & Rehabilitation and Operations | Ongoing | |||||||||||||||||
| 31/07/2025 | 10/08/2022 | Cloverhill Prison | Information | Record Keeping | 2022O5 | Death In Custody | Mr. O was not permitted to board a flight at Dublin Airport and was subsequently arrested at the airport by the Gardaí. This would suggest that he may have arrived at the airport with a valid form of identification. However, when committed to Cloverhill Prison Mr. O had no identification or personal belongings. The only identification on committal was a name on the warrant. The Inspectorate recommends that a Person Escort Record should be introduced and completed for every movement of a prisoner into or out of a prison whether by Irish Prison Service staff or Gardaí. This should include details of risks of self-harm and vulnerability in addition to security considerations and include any comments or threats made by a detained person. A similar recommendation was made in Ms. X 2019, published in November 2022. The Director General stated that “an information sharing group was established to look at information sharing between various Justice Bodies, they have begun the process of looking at the sharing of risk relevant information…”The IPS provided a quarter two 2024 update that “The Irish Prison Service has been engaging with An Garda Síochána with regard to the exchange of information …..” It is very disappointing that two years following a commitment by the IPS that an agreement in relation to the sharing of information, which can be critical to the preservation of life, has yet to be reached. | Accepted | 27/06/2025 | A revised version of this form was agreed by the Irish Prison Service, Probation Service and An Garda Síochána Information Sharing working group in Q2 2024 and submitted to An Garda Síochána for review and approval. | Operations Directorate | Ongoing | ||||||||||||||||
| 14/08/2025 | 09/10/2022 | Midlands Prison | Policy & Procedure | NOK Contact | 2022P1 | Death in Custody | The IPS should comply fully with its own protocol in relation to the notification of family (NoK) in cases of grave illness; by ensuring that family (NoK) is notified at the earliest opportunity when their relative becomes seriously ill and is hospitalised. A similar recommendation previously made in the case of Mr. I 2018 was accepted by the IPS. | Accepted | The IPS notify NOK in cases of grave illness insofar as is reasonably practicable, and subject to relevant security considerations. | Operations | Complete | |||||||||||||||||
| 14/08/2025 | 09/10/2022 | Midlands Prison | Healthcare | 2022P2 | Death in Custody | Where medical aids/equipment essential for the prevention of pressure sores are not working correctly or require replacement, these concerns should be communicated to the Chief Nurse Officer for immediate action. A second pressure sore might have been prevented had a pressure cushion been replaced in a timely way when concerns were first highlighted. It is of concern that Mr. P was left for 13 days without a functioning pressure cushion after a second pressure sore was identified. | Accepted | Written communication from Healthcare IPS HQ will be issued to all healthcare staff highlighting the importance of timely checking of medical aids and appliances and the reporting of defective equipment and the ordering of replacements | Care & Rehabilitation | Q42024 | ||||||||||||||||||
| 14/08/2025 | 09/10/2022 | Midlands Prison | Healthcare | 2022P3 | Death in Custody | Where it is recorded in PHMS that an antibiotic is to be prescribed for a Urinary Tract Infection or any other infection an updated entry should be made if the doctor subsequently decides that an antibiotic is contraindicated. | Accepted | Written communication from Healthcare IPS HQ will be issued to all IPS GPs will be reminded of the importance of entering contemporaneous notes when possible. | Care & Rehabilitation | Qr2024 | ||||||||||||||||||
| 14/08/2025 | 09/10/2022 | Midlands Prison | Healthcare | 2022P4 | Death in Custody | All urine and other samples taken should be sent to the laboratory for analysis on the date the sample is taken, thereby ensuring that treatment, if required, will commence at the earliest opportunity. | Not Accepted | Generally speaking, all clinically relevant samples are sent for laboratory analysis as soon as is practicable, but it is not always possible or necessary to send the sample on the same date it is taken. | Care & Rehabilitation | Complete | ||||||||||||||||||
| 12/04/2025 | 23/10/2022 | Wheatfield Prison | Healthcare | 2022Q1 | Death in Custody | The OIP invites the IPS to review its policy of the automatic cancellation of hospital appointments of which family members have become aware. It recommends that any decision to cancel an appointment for this reason should be based on an individualised written risk assessment and formally approved by the Governor of the prison concerned. | Accepted | 10/12/2024 | The Care & Rehabilitation Directorate and Operations Directorate will agree a more streamlined approach to the management of hospital appointments of which family members have become aware. This approach will likely focus on dynamic risk assessment between healthcare and operational management in prisons. | Care & Rehabilitation and Operations Directorate | Q1 2025 | IPS UPDATE REQUIRED - ONGOING Q1 2025 | IPS UPDATE REQUIRED - ONGOING Q1 2025 | IPS UPDATE REQUIRED - ONGOING Q1 2025 | ||||||||||||||
| 18/07/2024 | 25/12/2022 | Limerick Prison | Policy & Procedure | Healthcare | 2022T-1 | Death in Custody | It is recommended that an additional committal Interview question be included in the doctors and nurses interview to enquire from a new committal if there is a history of any serious illness in their family such as aneurysm, health condition, or cancer. This information would be beneficial in making clinical decisions. | Accepted | 02/08/2024 | IPS Healthcare and ICT are currently working on a number of improvements to the PHMS system. The inclusion of a committal interview question on family history will be prioritised as part of this work. | Care & Rehabilitation | Q4 2024 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 18/07/2024 | 25/12/2022 | Limerick Prison | Healthcare | Next of Kin | 2022T-2 | Death in Custody | When a prisoner is conveyed to hospital in a seriously ill condition the next-of-kin should be informed without delay thereby complying with section 2.3 of the Irish Prison Service Protocol ‘Chaplaincy and Next of Kin Notification’ which requires that that the family (next of kin) be contacted as quickly as possible in the case of grave illness. | Accepted | 02/08/2024 | Contact with next of kin will be made as soon as possible in line with the SOP requirements. This requirement will be brought to the attention of all lead Governors at the September meeting of the IPS Prisons Leadership Team. | Care & Rehabilitation | 45536 | 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 | |
| 18/07/2024 | 25/12/2022 | Limerick Prison | Policy & Procedure | Next of Kin | 2022T-3 | Death in Custody | Governors should, as a matter of good practice and courtesy, attempt to make contact with the NoK when a person dies in a prison for which they have responsibility. When a family are collecting personal belongings at a prison, they should always be met by a member of the prison’s management team. | Accepted | 02/08/2024 | These measures are not currently requirements under the IPS Chaplaincy and Next of Kin Notification SOP or the IPS Prisoner Property Policy. The IPS is due to commence the development of a Death in Custody policy and a review of related SOPs. These proposals will be considered as part of this process. Relevant changes will be reflected in the IPS Prisoner Property Policy. | Care & Rehabilitation and Operations | Ongoing | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | IPS UPDATE REQUIRED - ONGOING Q2 2025 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |
| 18/07/2024 | 25/12/2022 | Limerick Prison | Post-Incident Response | Prisoner Welfare | 2022T-4 | Death in Custody | It is recommended that when a death in custody occurs, prisoners who share a cell with the deceased should be offered immediate (emergency) psychological support as soon as practicable. | Accepted | 02/08/2024 | Local psychology teams work with the prison based MDT to identify cellmates of the deceased as well as other family or friends in custody. Psychological support will be offered as soon as possible. This procedure is already in place (see Psychology Protocol 021-101- 25; Psychologists Role in the Aftermath of a Critical Incident in Prison). | Care & Rehabilitation | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 18/07/2024 | 25/12/2022 | Wheatfield Prison | Record Keeping | 2022U4 | Death in Custody | When an error occurs with an entry on the PIMS in relation to a discharge/committal date the Assistant Chief Officer in charge of Committals and Discharges should notify the governing Governor who should immediately notify Operations Directorate to ensure that the error is rectified. | Accepted | 27/11/2023 | The Prison Governor has issued a reminder to relevant staff within the prison regarding their obligations in relation to the processing of temporary release applications and the management of a prisoner on temporary release. In addition to this, the Director of Operations has issued this reminder to lead Governors across the estate. | Prison Governor / Operations Directorate | Complete | 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 | ||
| 18/07/2024 | 25/12/2022 | Wheatfield Prison | Temporary Release | 2022U5 | Death in Custody | All personnel with responsibility for arranging and processing of a Temporary Release be reminded of their roles and responsibilities as set out in the Irish Prison Service Standard Operating Procedure relating to Temporary Release. | Accepted | 27/11/2023 | The Prison Governor has issued a reminder to relevant staff within the prison regarding their obligations in relation to the processing of temporary release applications and the management of a prisoner on temporary release. In addition to this, the Director of Operations has issued this reminder to lead Governors across the estate | Prison Governor / Operations Directorate | Complete | 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 | ||
| 18/07/2024 | 25/12/2022 | Wheatfield Prison | Record Keeping | 2022U6 | Death in Custody | IPS Management should ensure that all sections of official documents are fully and comprehensively completed in legible handwriting and all signatures are supported by block capitals. Similar recommendations have been made in Mr. L and Mr. Q 2019. | Accepted | 27/11/2023 | The Prison Governor has issued a reminder to relevant staff within the prison regarding their obligations in relation to the processing of temporary release applications and the management of a prisoner on temporary release. In addition to this, the Director of Operations has issued this reminder to lead Governors across the estate. | Prison Governor / Operations Directorate | Complete | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 31/10/2025 | 31/12/2022 | Cork Prison | Policy & Procedure | 2022V1 | Death in Custody | When a person, who has been granted Reviewable Temporary Release, fails to keep to their conditions, it is important that swift action is taken and all decision making regarding compliance, is accurately recorded. As Mr. V’s case demonstrates, in order to do this, there must be sufficient staff cover and systems in place when designated officers are on leave. The OIP believes that this could potentially be important for the welfare of those subject to temporary release conditions as well as for the wider community. In addition, if appropriate action is not taken when a person fails to comply with their conditions and does not have an acceptable explanation, the authority and legitimacy of the Temporary Release process could be called into question. | Not Accepted | The IoP recommendation has been considered and it is not proposed to change the approach taken to minor breaches. Where a person comes to the attention of An Garda Síochána on a period of temporary release in respect of offending, An Garda Síochána can return the person to custody immediately. Compliance with the conditions of temporary release are considered by the Irish Prison Service in the context of the consideration of the granting of a further period of temporary release. As part of that consideration, where a person has been deemed not to have complied with the conditions attaching to their temporary release, the person will be deemed to be unlawfully at large An Garda Síochána are notified accordingly in order to return the person to custody. | Operations | N/A | ||||||||||||||||||
| 24/02/2025 | 05/01/2023 | Mountjoy Prison | Healthcare | 2023A | Death in Custody | 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 | IPS UPDATE REQUIRED - ONGOING Q1 2025 | IPS UPDATE REQUIRED - ONGOING Q1 2025 | IPS UPDATE REQUIRED - ONGOING Q1 2025 | ||||||||||||||
| 29/07/2025 | 08/01/2023 | Wheatfield Prison | Next of Kin | 2023B1 | Death in Custody | 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 | |||||||||||||||||
| 30/10/2025 | 12/01/2023 | Limerick Prison | Safety | 2023C1 | 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 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 | ||||||||||||||||||
| 30/10/2025 | 12/01/2023 | Limerick Prison | Policy | 2023C2 | Death in Custody | 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 | ||||||||||||||||||
| 30/10/2025 | 12/01/2023 | Limerick Prison | Healthcare | 2023C3 | Death in Custody | 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 | ||||||||||||||||||
| 30/10/2025 | 12/01/2023 | Limerick Prison | Policy | Healthcare | 2023C4 | Death in Custody | 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 | |||||||||||||||||
| 30/10/2025 | 12/01/2023 | Limerick Prison | Policy & Procedure | Healthcare | 2023C5 | 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. 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 | |||||||||||||||||
| 30/10/2025 | 12/01/2023 | Limerick Prison | Safety | 2023C6 | Death in Custody | 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 | ||||||||||||||||||
| 30/10/2025 | 12/01/2023 | Limerick Prison | Safety | 2023C7 | Death in Custody | 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 | ||||||||||||||||||
| 30/10/2025 | 12/01/2023 | Limerick Prison | Record Keeping | 2023C8 | Death in Custody | 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 | ||||||||||||||||||
| 29/07/2025 | 26/01/2023 | Castlerea Prison | Record Keeping | 2023D1 | Death In Custody | 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 | Jul-25 | |||||||||||||||||
| 29/07/2025 | 26/01/2023 | Castlerea Prison | Record Keeping | 2023D2 | Death In Custody | 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 | 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 | |||||||||||||||||
| 29/07/2025 | 26/01/2023 | Castlerea Prison | Contraband | 2023D3 | Death in Custody | The record of Hot and Cold CIRM should show who was invited to attend; reasons for non- attendance; and anything significant that non attendees 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 | |||||||||||||||||
| 29/07/2025 | 26/01/2023 | Castlerea Prison | Policy | 2023D4 | Death In Custody | 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 | |||||||||||||||||
| 09/10/2025 | 17/07/2023 | Midlands Prison | Safety | 2023L1 | Death in Custody | 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 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 09/10/2025 | 17/07/2023 | Midlands Prison | Policy & Procedure | Healthcare | 2023L2 | Death in Custody | 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 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||
| 09/10/2025 | 17/07/2023 | Midlands Prison | Policy & Procedure | 2023L3 | Death in Custody | 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 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 09/10/2025 | 01/01/1970 | Midlands Prison | Safety | 2023L4 | Death in Custody | 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 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | |||||
| 09/10/2025 | 01/01/1970 | Midlands Prison | Policy & Procedure | 2023L5 | Death in Custody | 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 | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | NA | ||||||
| 18/02/2025 | 08/08/2023 | Mountjoy Prison | Policy & Procedure | 2023M1 | Death in Custody | The Director General of the IPS should formally remind all Governors that every cell in which a prisoner has died is to be preserved until it has been inspected by the OIP. | Under Consideration | The Irish Prison Service are currently legally required to preserve a cell for An Garda Síochána, but will review any agreement proposed by the OIP in relation to cell preservation. | Director General | N/A | ||||||||||||||||||
| 18/02/2025 | 08/08/2023 | Mountjoy Prison | Mental Health | 2023M2 | Death in Custody | Several prison officers, prisoners and family members reported having observed Mr. M display paranoia, social withdrawal and repeated behavioural changes. However, this did not result in enhanced monitoring or expedite his access to mental health or addiction supports. The OIP invites the IPS Director of Care and Rehabilitation to reflect upon the need to strengthen existing protocols in order to provide for more rapid access to mental health and addiction supports for prisoners presenting with this symptomology. | Accepted - Already in Place | Healthcare is available 24/7 in all closed prisons to care for those who present with a mental health or addiction concern. The Healthcare team engaged with Mr M on a number of occasions in response to concerns raised by operational staff and family members. No requirement for expedition to further supports was identified by the Healthcare team in this case. | Care and Rehabilitation | |||||||||||||||||||
| 18/02/2025 | 08/08/2023 | Mountjoy Prison | Policy & Procedure | Call Bell | 2023M3 | Death in Custody | Neighbouring prisoners initially activated their cell call alarms as they believed Mr. M had attempted to self-harm. However, it was 48 minutes later when an officer responded. The OIP recommends that a new national standard be introduced by the IPS requiring prison officers to respond rapidly to cell call alarms. Compliance with this standard should be closely monitored by prison management, including by reviewing electronic records of cell call alarm response times on a regular basis | Partially Accepted | The current cell call system that is being standardised across the Estate is a call system to attract the attention of the Officer and is answered as soon as possible. It is not an alarm or emergency response system. A rapid response system is currently being explored through a working group of Governors. The Governor of Operations has demonstrated this possible solution to the OIP and the rollout , if approved, will be subject to the availability of resources. | Operations Directorate | 2026 | |||||||||||||||||
| 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 | |||||||||||||||||
| 19/02/2026 | 08/03/2024 | Midlands Prison | Standard Operating Procedures | 2024H1 | Temporary Release | The investigation into Mr. H’s death has indicated that the lines of communication between different agencies, teams and specialities that operate within the criminal justice system are not always clear. This was evident on two occasions in relation to Mr. H. The first was when the Probation Service was not notified that Mr. H had passed away, despite Mr. H having an allocated probation officer. The subsequent establishment of a notification process, between IPS and the Probation Service, regarding a death in custody, is a welcome development. The second occasion was during the IPS healthcare team’s interaction with psychology regarding the referral processn in June 2023. Records indicate that Mr. H was to self-refer for psychology assistance, however psychology management has indicated this is not standard practice. The OIP recommends that clear guidance to be issued by the IPS Director of Care and Rehabilitation in relation to the referral process to psychology services. The guidance should include a requirement to document all relevant interactions between health care staff and psychology services insofar as they relate to the well-being of persons in custody. | Partially Accepted | People can self-refer to Psychology, however, they rely on a staff member to relay this to Psychology. All client referrals are required to be electronic referrals by any staff member, supported by a referral form. A protocol is in place for all staff setting out how to make a referral to Psychology (SOP No. 21-091 S006). High priority referrals can be flagged appropriately through multidisciplinary team meetings and supported by an electronic referral/referral form. All interactions between allied health professionals should be documented on PCTS/PHMS. | Care & Rehabilitation | Closed | ||||||||||||||||||
| 29/02/2026 | 08/03/2024 | Midlands Prison | Healthcare | 2024H2 | Temporary Release | In a published Death in Custody Report, Mr. I 2019, the OIP made a recommendation for the IPS to consider including Basic Life Support (BLS) training for recruit prison officers during the early part of their training and refresher courses for established staff. This recommendation was rejected by the IPS; however, it should be reconsidered as a matter of urgency. Unfortunately, Mr. H did not survive, despite the administration of early CPR by the officers who first attended to him. Yet, this case evidences how the swift actions of first responders provided Mr. H with the best chance of survival and at the very least, allowed time for his family to say goodbye to him. Officers trained in BLS could lead to more positive outcomes in the future. The OIP again recommends that the IPS include Basic Life Support (BLS) in training for recruit prison officers during the early part of their training and introduce refresher courses for established staff. | Not Accepted | 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. | HR (ISPC) | Closed | ||||||||||||||||||
| 19/07/2024 | 14/03/2024 | Cork Prison | Safety | Narcotics Detection | 2024K1 | Death in Custody | The OIP welcomes the IPS Drugs Strategy 2023 – 2026. In keeping with the objectives set out in that Strategy, it recommends that, in all cases where a prisoner is removed from his/her cell following a suspected overdose, a thorough search of the cell should immediately be conducted, in order to ascertain if any drugs remain hidden there. This search should be fully documented and information regarding the nature of any drugs found should be communicated to the prison’s healthcare team and, if the prisoner concerned remains hospitalised, to the hospital concerned. This requirement should be set out in an Irish Prison Service Standard Operating Procedure (SOP). | Accepted | 23/05/2024 | A national SOP will be drafted as soon as possible to support prisons in cases where a prisoner is removed from his/her cell following a suspected overdose. Documented cell searches will be required under the SOP. The SOP will also consider operational and/or accommodation issues which may impact decision making and actions taken, as well as outlining requirements for communication with healthcare. | Operations irectorate | 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 | 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 | ||||
| 19/07/2024 | 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 | |||||||||||||||||
| 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 | ||||||||||||||||||
| 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 | |||||||||||||||||
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