Prison governors should “seize and securely store” all “relevant original journals” kept by prison officers following any death in custody, the Inspector of Prisons has warned.
The call comes on foot of an investigation into the death of a young mother 10 days after she attempted suicide in the Dóchas women’s prison, in 2019. Though the investigator requested original journal entries by prison officers, pertaining to the nights the woman was remanded, these could not be found.
Monika Nawrat (33), originally from Poland, had been left alone in a cell with an exposed wall bracket, despite having been recommended for a shared cell by the prison nurse and her long history of self-harm.
Living in Bettystown, Co Meath, she had never been in prison when she was remanded in custody on October 3rd, 2019, as she could not pay €100 bail. She died in the Mater hospital on October 14th, 2019, having hanged herself in her cell on October 4th.
The Office of the Inspector of Prisons report finds Ms Nawrat’s vulnerability was not communicated among prison staff; she was not provided with information about her rights on arrival; her only phone call was incorrectly cut short.
Ms Nawrat had been before Trim District Court on a public-order charge. Though granted bail, she had only €5. She was held in the court cells pending transfer to the Dóchas Centre. She self-harmed, pulled hair from her head and was taken to Mullingar regional hospital. She was treated, prescribed medication for schizophrenia and taken by gardaí to the Dóchas Centre at 7.49pm on October 3rd, 2019.
When an escorting garda told the in-taking prison officer their late arrival was due to Ms Nawrat’s hospital attendance, the officer responded: “Another one”, the investigators were told by the Garda. The prison officer “adamantly” denied this. The garda said Ms Nawrat told another prison officer she would “kill herself”. The officer said he did not hear this but confirmed he knew her injuries were self-inflicted.
She was “not provided with information documentation on her arrival into the prison” until the next day.
A nurse “was satisfied that [Ms Nawrat] was not at risk of immediate self-harm [but] decided to assign her to a ‘shared vulnerable cell” – with two other women in the healthcare unit.
The prison governor saw her the next morning but was not told she had self-harmed. The prison doctor noted “she suffered from a long history of psychiatric ill health, chronic schizophrenia and substance abuse (cannabis)” but did not assess her as at risk. A chaplain arranged that she be allowed call her next-of-kin – named by Ms Nawrat as her family resource centre – to arrange payment of the bail.
A transcript of the call indicates her lack of knowledge about the system or how to get home. “I don’t know how this is working, I don’t know how this is paying. I don’t know nothing you know, nothing,” she told a support worker. Asked if she would get bus fare home, she said: “Oh I don’t know, I don’t think so ... Probably I’m going to be walking home.” The report says she would have been provided means to travel home.
“The call terminated abruptly mid-conversation after six minutes,” said the report, despite her right to a longer call.
This, says family-law solicitor Dorothy Walsh, who first complained to the Irish Prison Service (IPS) about the circumstances leading up to her client’s death, was “the turning point of total despair for her ... She did not know how she was going to get home.”
At 7.16pm she was locked back in the cell alone – the other two women having been moved. The investigation found she was checked 14 times between 8.44pm and 11.31pm – when she was found unresponsive. Paramedics transported her to the Mater, where she died 10 days later.
Investigators requested to see night-journal entries by prison officers for the nights of October 3rd and 4th. However, the IPS was unable to find the originals for either night but provided copies of what it said were the front of the journal for both, and of the October 4th entries.
Among the investigation’s nine recommendations are: “In the event of a death in custody the governor of the prison should seize and securely store all relevant original journals and issue new books”; all relevant prison staff be aware when a ‘shared vulnerable cell’ is recommended for a prisoner; and, if it is decided a ‘shared vulnerable cell’ is no longer required “a risk assessment should be conducted to justify de-escalation”.
It calls for a ‘person escort record’ for every movement of a prisoner into or out of a prison, to “include details of risks of self-harm and vulnerability”.
The Garda did not respond to requests for comment but the Garda Síochána Ombudsman Commission, in its investigation, concluded that “there had been no breach of Garda discipline regulations”.
An IPS spokeswoman said implementation of the report’s recommendations, including enhanced communication between healthcare and other staff, was “continuing”.
In the Dóchas centre, multi-agency management meetings now always include all healthcare disciplines, chaplaincy and probation. It is “patient/prisoner centred”, she said, and meets weekly, chaired by the governor.
“The Irish Prison Service are also in the process of implementing a new intervention approach, Collaborative Assessment and Management of Suicidality, in the Dóchas.”
The Samaritans can be contacted for free on the 24/7 phone helpline 116 123, or people can email jo@samaritans.ie or visit samaritans.ie.
