Interim Prisoner Ombudsman publishes report into a Death in Custody in Maghaberry Prison
Published on April 28 2025
Mr Ramage was 47 years old when he died in Maghaberry Prison on 18 September 2020, having been admitted to custody on 14 September 2020.
Mr Ramage had been in custody at four different periods during 2020, serving two of these sentences during the Covid-19 pandemic.
On 1 June 2022 Mr Ramage was committed to Maghaberry Prison and completed a Committal Risk Assessment. On 2 June 2020 his Mental Health Screening was completed. At 17.50 that day he was found unresponsive in his cell and was transferred to hospital. On 3 June 2020 Mr Ramage confirmed that he had attempted to end his life and staff put a care plan in place.
On 7 June 2020 he was returned to Maghaberry Prison where he was referred to the Addictions Team and was placed on supervised administration for his medication. Mr Ramage was released from custody on 17 July 2020.
Mr Ramage returned to custody on 14 September 2020, where a Committal Risk Assessment was completed and he was found not to be at ‘No Apparent Risk’. On 15 September 2020 an Initial Healthcare Assessment and a Contingency Risk Assessment were completed and these found Mr Ramage to be unsuitable for in-possession tablets. However, he was permitted to keep his insulin pens in cell as this is standard practice given the high risk associated with not being able to access insulin when required.
On 16 September 2020 Mr Ramage attended a Comprehensive Committal Assessment.
On 17 September, Mr Ramage received his medication and engaged with a Prison Officer at approximately 19.00. The Night Custody Officers undertook 11 checks between 19.30 and 07.00 on 18 September. At 08.47 Mr Ramage was found to be unresponsive by landing staff. At 08.51 medics arrived on the scene and at 09.24 Mr Ramage was pronounced dead.
The Independent Clinical Reviewer concluded that the care Mr Ramage received in Maghaberry Prison was to standard and could be considered as equivalent to, or of equal standard to, that provided in the wider community. The Prisoner Ombudsman agreed with the Independent Clinical Reviewer's findings, and was satisfied that Mr Ramage’s mental state and thoughts of self-harm were discussed and challenged at each relevant encounter.
The report has two recommendations, one for Prison Service on Committal Calls procedures, which the Prison Service will share actions on, and one for the South Eastern Health & Social Care Trust (Trust) on Healthcare in Prison Committal Procedures. The Prisoner Ombudsman has also noted a previous recommendation on the need for review on how information related to the risk of suicide or self-harm is shared to ensure Prison Officers have the information they need to respond appropriately to individuals in custody and their behaviours.
Speaking on the publication of the report into Mr Ramage's death, the Interim Prisoner Ombudsman, Jacqui Durkin, said:
“The Covid-19 pandemic was a very difficult time for people committed to and working in prisons in Northern Ireland. When individuals who are committed to prison have mental and physical health needs, it is essential that they are provided with appropriate support and that all assessments of their needs are thorough. Mr Ramage had insulin-dependent diabetes and a history of poor mental health, and the circumstances of his death are tragic for his family. While the Clinical Review found that the care Mr Ramage received was equal to what would have been provided in the wider community, there is learning for the Prison Service and the Trust and I am pleased the two report recommendations have been accepted.”
The Interim Prisoner Ombudsman expressed her condolences to Mr Ramage's family:
“I offer my sincere condolences to Mr Ramage’s family on their sad and painful loss. I hope this report provides information to address some of the questions they raised and explains events leading up to Mr Ramage’s death. The report recommendations will hopefully bring some comfort and confidence to families whose loved ones are in custody.”
Ms Durkin also extended thanks to the Prison Service, the Trust and the Clinical Reviewer for their contributions to the investigation.
The full report can be accessed here [LINK TO BE ADDED]
This report was at an advanced stage when the former Prisoner Ombudsman, Dr Lesley Carroll, ended her appointment term on 29 February 2024. On 25 March 2024 Jacqui Durkin, Chief Inspector of Criminal Justice in Northern Ireland, was appointed Interim Prisoner Ombudsman while the process for a new appointment process for a substantive Prisoner Ombudsman is undertaken.
Further information:
Brendan Scott
MW Advocate
07834422923
brendan.scott@mwadvocate.com