Prisoner Ombudsman publishes report into a Death in Custody

Published on March 22 2023

James Fleck died in hospital on 08 March 2019, after being found unresponsive in his cell in Maghaberry Prison on Sunday 03 March 2019, the day after he was remanded. He was 24 years old.

Mr Fleck was a young man who had to deal with many complex issues and challenges: he had a history of anxiety, depression, self-harm and longstanding drug dependency; he had been in custody 8 times in the last 5 years of his life.

On his committal to Maghaberry on Saturday 02 March 2019, Mr Fleck was identified as being at risk of self-harm or suicide. The prison's Supporting People At Risk Evolution (SPAR Evo) operating procedures were initiated and he spent his first night in custody in an Observation cell where Prison Officers could easily monitor him every 15 minutes.

The next morning Mr Fleck moved to a regular cell where he remained on the SPAR Evo care plan and the frequency of his observations were reduced from every 15 minutes to every 60 minutes. During the day he spent some time in the Prison Yard and made a phone call to his partner before returning to his cell.

In line with the weekend regime his cell was locked at 16.30 and Prison Officers chose to increase the frequency of observations to approximately every 30 minutes throughout the evening of Sunday 03 March 2019.

When a prison officer checked on him at approximately 21.05 he was unresponsive and prison staff immediately attempted resuscitation with the assistance of Healthcare in Prisons professionals from the South Eastern Health & Social Care Trust (the Trust).

Mr Fleck was transferred by ambulance to Craigavon Area Hospital where he remained in the Intensive Care Unit until his death on Friday 08 March 2019. An inquest is pending and the Coroner will decide the cause of death.

The Clinical Reviewer found that overall the care provided to Mr Fleck by Healthcare in Prisons staff was equivalent to the care he would have received in the community and the emergency response was well delivered and in line with resuscitation guidelines.

Speaking on the publication of the report into Mr Fleck's death, the Prisoner Ombudsman, Dr Lesley Carroll said:

"I am concerned that individuals with significant addictions, anxiety and depression find themselves in custody. The fact that Mr Fleck was in prison is a matter for the courts. And yet, he is not alone in returning to prison on a number of occasions while continuing to be medicated for anxiety and depression and in need of addiction services."

Dr Carroll referred to the concerns she had raised in August 2020 with the Director for Reducing Offending and representatives of the Trust, about adequate information being shared between community and prison healthcare and between services working within prisons. She asked for her issues of concern to be considered by the Departmental Health and Justice Improving Health within The Criminal Justice Implementation Group.

"We need to ensure that individuals in custody receive the best possible healthcare and to deliver this there needs to be alternative models of care which are informed by the death in custody investigations into Mr Fleck's death and others.

"I am supportive of the approach taken by The Regulation Quality and Improvement Authority in its 2021, Review of Services for Vulnerable Persons Detained in Northern Ireland Prisons, however I am deeply concerned that the resources required will not be made available given the current demand on resources and the inertia in decision-making without an Assembly at Stormont."

The Ombudsman thanked the Prison Service, the Trust, the Clinical Reviewer and others who had contributed to her investigation into Mr Fleck's death and expressed her condolences to Mr Fleck's family:

"The death of a loved one is always difficult. The fact that a death occurs while someone is in prison custody has particular difficulties. In Mr Fleck's case, this has been all the more difficult for his family in that he had been in custody on other occasions and on this occasion he was found unresponsive a day after he was admitted into custody. I am grateful to Mr Fleck's family for their contribution to this investigation and I appreciate their patience. I am very conscious that Mr Fleck's family offered him considerable support with the challenges he faced. I offer my sincere condolences to them on their sad loss and hope this report provides information to address some of the questions they raised and explains events leading up to Mr Fleck's death."