Progress in the
Penal System (PIPS)

25: Investigations into deaths in custody (2019)

Standard 25:

The death of, or serious incident involving, a prisoner is investigated by an independent body immediately and the investigation report is published promptly.


The State has a duty of care to all persons in its care.[458] As highlighted by Penal Reform International (2018), state authorities are obliged to carry out an independent, impartial, prompt and effective investigation into the circumstances and causes of any serious incident and to provide reparation or redress to victims and/or their families.[459]

Current context:

To date in 2019, there have been three deaths in custody reports published on the Office of the Inspector of Prisons and Department of Justice and Equality websites.[460] Of these, two reports relate to deaths that occurred in 2017 and one death in 2018.

Indicators for Standard:

Indicators for Standard 25

Indicator S25.1: Implementation of recommendations of investigations made by the OiP.

In 2019, the OiP criticised the fact it had been forced to repeat the same recommendations in its published reports, due to the failure of IPS to implement them:

It is of serious concern that this Office is repeating recommendations over and over again and the opportunity to prevent recurrence of similar deaths does not appear to be sufficiently addressed.[461]

The Inspector particularly noted the lack of compliance with checks for prisoners under ‘special observations’ and the failure of the IPS to retain CCTV footage. The Inspector welcomed the response made by the director general of the IPS, who accepted the recommendations and set out the steps that IPS would be taking to ensuring their full implementation. Further updates were provided to the Inspector by the director general on various dates.[462] This includes a range of measures introduced in relation to special observations.


Up to July 2019, fewer death in custody reports had been published than previous years. There appear to be significant delays in the publication of death in custody reports, with often over a year between the date a prisoner dies and the date the report is published by the Minister for Justice and Equality. These delays may mean Ireland is not in compliance with our obligations under the ECHR. It may also mean delays in working towards the implementation of a recommendation that could prevent a re-occurrence of circumstances associated with the death of a prisoner.

Recurrent issues, such as non-compliance with standard operating procedures and failures by the IPS to retain or record CCTV footage, have been identified by the Office of the Inspector of Prisons. Follow-up actions taken by the IPS in response to issues identified by the Inspector should be published. This would hold the State to account in ensuring recommendations are acted upon following the death of an individual while under the care of the State.

Status of Standard 25: No change

Actions required:

Action 25.1: Reports on progress towards implementation of recommendations made by the OiP following deaths in custody should be regularly published by the Irish Prison Service.


Irish Penal Reform Trust


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