New Prisoner Ombudsman publishes his first report into a Death in Custody.
Published on April 28 2025
Jason Weir died at Magilligan Prison on Tuesday 9 February 2021. He was 33 years old at the time of his death.
The report by the Prisoner Ombudsman makes a number of recommendations to the Northern Ireland Prison Service (Prison Service) and the South Eastern Health and Social Care Trust (SEHSCT/Trust) in respect of early psychiatric and neurology referral and follow-up, risk assessment and Parole Commissioners directions for assessment. Both the Prison Service and Trust have responded to the Prisoner Ombudsman’s Office indicating how they intend to address the recommendations. The Trust have advised that they do not accept the first recommendation that relates to early psychiatric and neurology referral and follow-up.
Mr Weir was committed to Maghaberry Prison on 17 January 2012, and was later transferred to Magilligan Prison on 16 January 2020. Throughout his time in prison he received treatment for his mental health and anxiety, regularly saw mental health professionals and was on a Supporting People at Risk Evolution (SPAR Evo) Care Plan. At the time of his death he had been referred to a neurologist and was awaiting a full psychiatric assessment following a Direction by a Parole Commissioner .
On Tuesday 9 February 2021 Mr Weir was found unresponsive in his cell. Despite attempts, he could not be resuscitated and his death was pronounced at 8:15am.
As part of the Death in Custody investigation a Clinical Review was undertaken into Mr Weir’s treatment and care. This review found that, while Mr Weir’s care in custody was of equivalence to what he would have experienced had he been in the community, the exploration of possible organic causes for his illness was not equivalent. Mr Weir was referred for a neurology consultation in December 2019 and when it was eventually followed up it was treated as urgent by the consultant; however it had not taken place by the time of his death in 2021. As a vulnerable prisoner, the Ombudsman believes Mr Weir was reliant on Healthcare in Prisons (HiP) staff to query the progress of his referral; however, the Trust do not agree they had any role in expediting his access to a neurology consultation appointment.
Since Mr Weir’s death, the Prison Service and Trust have commissioned a joint external review of the Supporting People at Risk Evolution (SPAR Evo) procedure. The final report was completed in May 2024 and it contains a number of recommendations that should enable better information sharing between the Prison Service and the Trust as well as support for those individuals in custody. The Prisoner Ombudsman has welcomed this report and looks forward to its implementation.
The Prisoner Ombudsman thanked Mr Weir’s family for their input into the investigation:
“Mr Weir’s death was a tragic experience for this family, and in the process of this investigation, they have put forward a number of questions relating to him and his care in prison. While it is not possible to answer all their questions, I hope that this report can go some way to addressing their concerns.
“This report makes three recommendations which, when implemented, can have a positive impact on other prisoners who may have psychiatric or mental health needs. Significant in this report was the time delay following the Parole Commissioner’s first direction to obtain a full written psychiatric assessment report of Mr Weir and the need to refer this back to the Commissioners. This assessment was not carried out nor the report provided before Mr Weir died, a fact which is regrettable and led to the parole hearing being adjourned. Parole Commissioner’s directions must be treated the same way as a Court Order and it is essential that prisoner assessments and resultant reports directed by Parole Commissioners are carried out as soon as operationally possible and without undue delay.
I accept that the NIPS has no authority to compel or direct HiP on compliance with or adherence to Parole Commissioners Directions or any aspect of physical and mental health treatment or interventions, but I believe it is reasonable to expect positive collaboration between agencies in the interests of prisoners’ care and treatment outcomes.
Further information:
Brendan Scott
MW Advocate
07834422923
Notes to Editors:
This report was at an advanced stage when the Interim Prisoner Ombudsman, Jacqui Durkin, Chief Inspector of Criminal Justice in Northern Ireland, completed her term on 31 October 2024. Darrin Jones KPM was appointed by the Minister of Justice as the new Prisoner Ombudsman for Northern Ireland on 1 November 2024 for a three year term.
SPAR Evo is the Supporting People at Risk Evolution Procedure, which help mitigate risks to
vulnerable prisoners who have been identified as at risk of self-harm or suicide.