Progress in the
Penal System (PIPS)

25: Investigations into deaths in custody

Standard 25:

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


The State has a duty of care to all persons in its care. [539] As highlighted by Penal Reform International [540] (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.

Current context:

A number of prisoner deaths occur in prison and on temporary release every year. An international study from 2017 highlighted the increased risk of suicide for the prison population; male prisoners were found to be three times more likely to be at risk than the general male population and women in prison nine times more likely to be at risk than the general female population. [541]

A recent analysis [542] shows that of 87 death-in- custody reports published since 2012, 12 reports raised the issue of the lack of record keeping and failure to comply with Standard Operating Procedures relating to prisoner checks.

Penal Reform International [543] outlines a number of questions that monitoring bodies could be asking relating to deaths in custody:

Death in Custody Reports 2017: Date of Death vs. Date of Publication of the Inspector of Prisons’ Report by the Minister for Justice and Equality

Outlined below is information related to the date of death and the length of time before publication of the investigation report for deaths in custody reports published to date in 2018.

2016, Prisoner Date of Death IoP Completion of Report [544] DJE Publication [545]
Prisoner J (2016) 4th December 2016 22nd December 2017 26th April 2018
2017, Prisoner [546] Date of Death IoP Completion of Report [547] DJE Publication [548]
A 3rd January 2017 30th November 2017 27th March 2018
B 3rd January 2017 30th November 2017 23rd February 2018
C 6th March 2017 20th December 2017 20th August 2018
D 19th March 2017 20th December 2017 23rd February 2018
E 25th March 2017 15th March 2018 18th July 2018
F 13th April 2017 15th March 2018 25th July 2018
G Not known/ unpublished
H 15th May 2017 20th December 2017 23rd February 2018
I 13th August 2017 15th September 2017 12th October 2017
J Not known/ unpublished
K 2nd October 2017 30th November 2017 17th January 2018
L 6th October 2017 7th December 2017 17th January 2018
M 11th October 2017 10th April 2018 30th July 2018
Year 2018 Date of Death IoP Completion of Report DJE Publication
B 27th January 2018 26th March 2018 7th August 2018
E 19th February 2018 26th April 2018 15th June 2018

Indicators for Standard:

Indicators for Standard 25

Indicator S25.1: Implementation of recommendations of investigations made by the Inspector of Prisons: While the number of recommendations fully implemented by the Irish Prison Service is not known, the Irish Prison Service has developed a matrix of recommendations and specific actions have been assigned to various stakeholders. [549]

Actions required:

Action 25.1: Standard Operating Procedures should be followed by prison staff at all times.
Action 25.2: The Inspector of Prisons should be given the authority to publish reports directly. In the absence of this, the Department of Justice and Equality must commit to publishing investigation reports in a prompt manner.
Action 25.2: The Irish Prison Service should publish its plans/progress for the implementation of recommendations arising from the Inspector of Prisons’ death in custody reports.


IPRT Irish Penal Reform Trust


Copyright 2019 Irish Penal Reform Trust. CHY number: 11091

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