THE DIRECTOR GENERAL of the Irish Prison system, Michael Donnellan, has said that that the legacy of the tragic death of Gary Douch in Mountjoy Prison in August 2006 will be “dramatic improvements” in the Irish penal system. It is indisputable that there have been significant improvements in Ireland’s prisons since this appalling death, and this progress is to be welcomed and openly acknowledged.

But it would be inaccurate to conclude that the failings identified in this report of the Commission of Investigation into the death of Gary Douch have been entirely consigned to the history books.

An unacceptable delay for a report on this horrific death

Gary Douch’s mother, Margaret Rafter, has been waiting for seven-and-a-half years for this report. The State has a legal obligation under Article 2 of the European Convention on Human Rights to provide a prompt and effective investigation into the death of any prisoner. There is a clear rationale for expediency in investigating a death of this kind: when a vulnerable prisoner dies behind closed doors on the State’s watch, there is a crucial public interest in knowing exactly what has happened, how it happened, and what steps have been put in place to ensure it never happens again. We are calling on the Minister to ensure that no other family will be subjected to such an unacceptable delay in future.

The report found that overcrowding was “undoubtedly one of the key contributing factors” in the death of Gary Douch, and that there was a “reckless disregard” for the health and safety of staff and prisoners at Mountjoy Prison, which they knew was under severe pressure from overcrowding.

There has been much commentary on the fact that the situation in Mountjoy is now improved from the situation in 2006. It is true that there has been a reduction in numbers in that prison (602 today, down from a peak of 710 in March 2011). But the fact is that on the very day that this report was published, five prisons in Ireland were still overcrowded and operating beyond their maximum capacity, with Limerick Female Prison at 129%. Castlerea Prison was accommodating 361 men in a prison that should never accommodate more than 300, according to the Inspector of Prisons. Cork Prison, where prisoners are still forced to slop-out, held 231 in a prison designed for 173.

Setting and maintaining safe custody limits

The brutal death of Gary Douch was avoidable; the report confirms this. To avoid future tragedy, the Irish Prison Service must set and maintain safe custody limits, aligned with the recommendations by the Inspector of Prisons, and it must not breach these limits. The principle of imprisonment as a last resort must be enshrined in our criminal justice system. As the report confirms, the implementation of alternative sentencing options could also “deliver measurable benefits all round, including significant costs benefits”.

Two prisoners were failed by the system, not forgetting the five other prisoners in the cell who witnessed the horrific events. Gráinne McMorrow SC has identified that Stephen Egan had a serious and severe history of mental health problems. She has forensically analysed both the failings in the treatment provided and the resulting threats to the safety of both staff and other prisoners, but more importantly, she has provided a series of comprehensive recommendations on improving mental health services in Irish prisons.

We welcome the Minister’s statement that the Strategic Review Group on Mental Health will carefully consider these recommendations, and we await the announcement of concrete plans from the Minister and the IPS on exactly how and when they will implement these vital recommendations.

A culture of inattentiveness

Perhaps most worryingly, this report found a “lack of accountability and culture of inattentiveness” prevailed in the prison system. Behind bars and hidden out of sight, enormous power differentials exist. Despite repeated calls from a number of international committees and monitoring mechanisms, Irish prisoners still do not have access to an independent complaints mechanism or a Prisoner Ombudsman.

Gráinne McMorrow echoes the calls of many others, including IPRT, in suggesting that the establishment of an Office of Prisoner Ombudsman should be considered with a statutory remit to investigate prisoner complaints. These events have yet again underlined the need for reform of existing monitoring structures and the establishment of an oversight mechanism fully independent of both the Irish Prison Service and the Minister for Justice.

The statement of Ministers Shatter and Lynch yesterday frankly acknowledged the “catastrophic failings” which led to the death of a young man. There was an important and welcome apology and the Minister expressed his commitment to “ensure there is no possibility of this happening again”. We now need to see the implementation of these recommendations without delay.

If it is possible for there to be any positive legacy to this tragedy, then it must be the expedient adoption of these recommendations. It would further demonstrate the commitment to tangible improvements in the prison system at the highest level, and would hopefully provide some consolation, however meagre, to the family of Gary Douch.

Deirdre Malone is Executive Director of the Irish Penal Reform Trust.

Read: Death of Gary Douch, killed in Mountjoy, was “avoidable and should not have happened”