Updated 1 February to include clarifications from an inquest.
A REPORT FROM the state’s prison watchdog into the death of a man in Cork Prison more than two years ago has revealed that the man who died told a nurse on being committed that he had previously attempted to “hang himself in Garda custody”.
The report also states that prison staff were aware that the man was suffering “delusions” prior to his death. However, during its investigation, the Office of the Inspector of Prisons (OIP) also found that staff had checked on the prisoner 13 times in the four-and-a-half hours prior to his suicide attempt.
Furthermore, an inquest into the man’s death two days after the publication of the report heard that a nurse wanted to clarify that the prisoner did not tell them about the attempted suicide during the 2020 committal interview, but that they noted it from computer records from 2018 after they talked to him.
Andrew Gearns, 29, a father of two from Model Farm Road in Cork City, was found unresponsive in his cell on 28 September 2020 as a result of an attempted hanging. He passed away in Cork University Hospital on 7 October.
A report delivered by the OIP yesterday details concerns that Mr Gearns’s family had about how he was cared for in Cork Prison.
The family said that the father of two was an “active person” who once held a senior position in an engineering firm before he became seriously injured in a road traffic collision, and subsequently became addicted to medication which led to the use of “controlled substances”.
His mother told the OIP that she received a call from gardaí while she was taking Mr Gearns to the dentist, informing her that they had a warrant for his arrest.
His mother said she explained to gardaí that Mr Gearns was in a “bad place” when she took him to meet them at her mother’s house, and that she felt reassured by the officers that they would “take care of him”.
When later asked by the OIP, the gardaí who arrested Mr Gearns said they did not recall any concerns for his welfare being raised, and that they did not have “any reason to report anything” to the Irish Prison Service (IPS).
The only paperwork handed over when Mr Gearns, who is referred to in the report as ‘Mr K’, was committed, was the warrant of detention.
On Tuesday 22 September, Mr Gearns was brought to Cork Prison but no documents regarding any known information of health or security risks were exchanged between gardaí and the IPS.
In its report, the OIP included information that the Gearns family obtained through Freedom Information requests, which show that Risk and Alert assessments carried out when the Cork man was previously arrested stated that he had attempted to hang himself while in Gardaí custody in 2018.
On being committed to Cork Prison, Mr Gearns was interviewed by a nurse who questioned him in relation to his “mental health history”.
During this interview he informed ‘Nurse A’ that he had deliberately self-harmed before. He stated that he had “tried to hang himself while in Garda custody last week”, adding that he was “off his face on benzos”. (The OIP established that the incident he was referring to occurred in 2018, not in 2020.)
He also disclosed a history of substance abuse and withdrawal seizures. Following the interview, the nurse noted that Mr Gearns smoked heroin, which he had “last smoked earlier today”.
The nurse also noted that Mr Gearns had “no suicidal ideation or intent. Denies of any history of anxiety. Guarantees his own safety – states he will not harm himself when questioned”.
The nurse recommended that Mr Gearns be accommodated in a “Shared Normal Cell”, but due to quarantine measures during the Covid-19 pandemic being implemented in the prison at the time, he was allocated a designated isolation cell.
“Mr K was accommodated on his own in a cell furnished for double occupancy including a bunk bed… He was permitted to retain his own clothing…,” the report states.
On the 23 September, a prison doctor assessed Mr Gearns, and recorded a note stating that Mr Gearns had tested positive for heroin, opiates and benzo, adding that he would be started on a “non-opiates detox”. The doctor did not make any written reference to any history of self-harm or any risk-related review.
The report states that a Governor’s committal interview was also carried out with Mr Gearns, though it was not in person due to Covid-19 distancing measures. Prison staff could not say whether it occurred over the phone, or through the observation hatch of his cell. There was no entry made by the Governor under “other concerns” afterwards in his notes, and there was nothing recorded in relation to risks or concerns for Mr Gearns’s safety or wellbeing.
The report details how Mr Gearns went through withdrawal aches and pains, and suffered a loss of taste and smell, which eventually returned, during his time in custody.
On 24 September, a doctor recorded that Mr Gearns met the criteria for methadone detox, and that he would be started on a 21-day programme.
The report states that on several occasions Mr Gearns refused medication while in Cork Prison, but he did take it on occasion.
On Sunday 27 September, according to the report, a nurse received a call from a prison officer who requested that Mr Gearns be assessed, as he “appeared to be suffering delusions”.
The nurse recorded a note stating that Mr Gearns “seem[ed] to be a some [sic] sort of brief reactive psychosis without stressors, no previous psychiatric history noted”.
The nurse also wrote that Mr Gearns believed he had been stabbed and that the culprits were outside of the prison. The notes further detail how Mr Gearns advised the nurse that he had no thoughts of self-harm or suicide, and “guaranteed his own safety”.
Further notes made by nurses at the time, included in the report, state that Mr Gearns said he had been let out of the prison for a walk and was stabbed in Blackpool, and that he asked to see a GP to get his wounds treated.
A nurse recorded notes which stated that he appeared to be “hallucinating”, and confirmed they would arrange a doctor’s appointment.
On 28 September, the report states, a nurse recorded that Mr Gearns was “oriented to place” but he did not know the month or year, while he did know his name and date of birth. He was then scheduled to meet a psychiatrist the following day – Tuesday 29 September.
Mr Gearns’s mother spoke to him for six minutes on the same day.
She later informed the OIP inspectors that during that conversation, Mr Gearns had told her that his girlfriend had attended Cork Prison the night before, and that he had been brought to Blackpool, where he claimed to have sustained injuries.
She said she immediately became worried for her son’s safety, and called the prison to speak with a nurse and voice her concerns. She told OIP inspectors that the nurse informed her that her son was hallucinating and was not making sense, and that staff were keeping a close eye on him.
The report states that on 28 September, CCTV footage showed that from the time the nurse received a phone call from Mr Gearns’s mother just after noon to being found unresponsive, the prisoner was checked 13 times in his cell by prison staff – more times than is required as per the IPS’s operating procedures. Just before 5pm, a prison officer checked his cell and immediately called a ‘Code Red Alert’.
One minute later the prison officer and the Assistant Chief Officer entered the cell and reported cutting ligature and placing Mr Gearns on the floor. Fourteen minutes later ambulance staff arrived; CPR was administered in the interim.
Mr Gearns’s mother has told inspectors that the “lack of information” following her son’s death from the prison caused her “stress and upset”. She recalls being told about his death by Mr Gearn’s partner, who was informed by the prison as his next of kin.
The family have raised several other concerns about the quality of care Mr Gearns received. The OIP responded to their eight questions in the report, detailing aspects of his medication regime and checks on his cell, while also telling his mother there was no evidence he was screaming on his own for six days as she feared.
The cause of his death is still to be determined by a Coroner’s inquest, which is ongoing.
The OIP has made a list of recommendations in order to avoid further deaths similar to this case, including that the IPS should introduce a Person Escort Record, which should be completed for every movement of a prisoner into or out of a prison by Gardaí or prison staff. This, it said, should include detail of all known risks of self-harm and vulnerability in addition to security considerations.
The OIP also recommended that information about a prisoner’s previous history of self-harm in the Risks and Alerts system should be recorded on the Prison Information Management System and all prison staff with a duty of care to that prisoner, including the Governor, should be made aware of it.
It further recommended that identification of potential ligature points and items of potential self-harm to those at risk should form part of daily inspections and policy in all prisons.
The OIP stated that anti-ligature detention furniture should be evaluated for use when necessary to “mitigate self-harm”. They provided an image of such items used in other jurisdictions.
In response to the OIP report, the IPS said it accepted two of the recommendations but only partially accepted the remaining two, including the suggestions about cell furniture and daily checks for potential self-harm risks.
In its response, the IPS said all the furniture it purchases is already evaluated for degrees of risk and that its Health and Safety Officer assesses all suppliers’ products to ensure they conform to Health and Safety and legal requirements.
However, it has committed to undertaking a review in the first three months of this year to evaluate anti-ligature detention furniture.
In relation to cell inspections, the IPS said: “Daily checks are currently being carried out by staff whereby they look for damage in the cell which could cause a health and safety issue. If there are any issues they are recorded in the Hazard Report Book and action taken if required.”
It added, “Operations Directorate will review the IPS fault Hazard Sheet which is filled on a daily basis by the class officer with regard to ligature points.”
Accepting the recommendation about handovers, the IPS said it has been engaging with An Garda Síochana and there are plans to enhance the level of information shared.
In relation to the risk alerts, the IPS said a system is currently in place to allow staff to be informed of any prisoner having a high risk of self harm.
An inquest into Mr Gearns death is due to continue in Cork City Coroner’s Court tomorrow.
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