Published Wednesday, 06 August 2014
Maghaberry Prison, where Mr Brown was found in his cell in a collapsed state. (© UTV)
In a report into the death of David Brown, 46, at Maghaberry prison just over 18 months ago, the watchdog found that there were delays in responding to the medical emergency.
Brown, who was in prison for murder at the time, died from a brain haemorrhage at a hospital on 15 December 2012, which the Prisoner Ombudsman Tom McGonigle said could not have been prevented.
Brown had been complaining of headaches and was seen twice by healthcare staff.
The statement went on to say that when Mr Brown was discovered in an unresponsive state in his cell, the NI Prison Service (NIPS) response was inadequate.
He was left unattended for five minutes, the alarm was not immediately raised, other prisoners were not locked up and entered his cell during the emergency and the nurse was not made aware that it was an emergency situation.
The newly recruited officers, who found Mr Brown, had finished their training four weeks previously. Both said they had not been trained in how to deal with this sort of incident - however, the Prison Service contradicted this.
A neurologist said his haemorrhage was not survivable.
The independent consultant neurosurgeon enlisted by the Ombudsman did not criticise his medical management at the prison and did not feel an opportunity to achieve an earlier diagnosis existed, or that another outcome could have been achieved.
The report recommended NIPS should ensure that all new recruits are able to identify potential emergencies and act swiftly and appropriately upon them.
It said clear instructions should be produced to determine what actions are to be taken when a prisoner has been found unconscious.
The service was warned to ensure meaningful support was provided to staff following every death in custody.
The Prisoner Ombudsman statement continued: "Toxicology tests revealed painkilling drugs in his system. These had been prescribed to him, and were at concentrations that lay within their respective therapeutic ranges.
"No other common drugs were detected in his system. This is important as there was speculation about a white powdery substance that was found around Mr Brown's nose at the time of his death."
It was not possible to establish what the substance was.
Prisoner Ombudsman Tom McGonigle, in expressing sympathy to the next of kin, said: "While some things could have been done better, a key finding of this independent investigation is that there was no possibility to achieve an alternative outcome for Mr Brown."
© UTV News