An Garda Síochána is not the only agency of the State that is dysfunctional.

A report published earlier this month by senior counsel Gráinne McMorrow on the killing of a prisoner, Gary Douch, in Mountjoy jail, suggests the prison system is also dysfunctional.

Gary Douch was serving a three-year sentence on conviction for assault causing harm. He was transferred from the Midlands Prison to Mountjoy on July 24th, 2006, and placed in cell 17 on “C” wing. A week later he asked to be moved from “C” wing because he feared he was going to be attacked by other prisoners.

Because of overcrowding in Mountjoy, Gary Douch was transferred to a holding cell in what is known as “B Base” on the evening of Monday, July 31st, 2006. Seven prisoners, including Gary Douch, ended up spending the night in the holding cell, which was never intended as an overnight accommodation facility.

Among the other prisoners in the holding cell was Stephen Egan, who had been transferred from Cloverhill Prison two days previously. He could not be accommodated otherwise in Mountjoy because he too was in danger of being attacked by other prisoners.

Stephen Egan had a history of extreme violence and mental disturbance. Over a period of 2½ years he was moved on 17 occasions from one prison to another. In November 2005, as he was being transferred between prisons, he placed his rigid metal handcuffs over the head and around the throat of a woman prison officer. In December 2005 he set fire to his cell, claiming he had visual and auditory hallucinations. There were several other such incidents and in July 2006 he was moved to the Central Mental Hospital in Dundrum, Dublin.

He was diagnosed there as “acutely psychotic” and he was kept in a seclusion cell because of a perceived risk of serious violence based on his prison disciplinary record.

Discharged
He was discharged from the Central Mental Hospital on July 14th, 2006, and sent to Cloverhill. There was no documented evidence that Stephen Egan was seen by any member of the psychiatric service while he was in Cloverhill, nor did he undergo the usual medical procedures on his arrival there.

A psychologist who examined him at that time, at the request of Stephen Egan’s solicitor (this had to do with an imminent court hearing on sentencing), described him as “manic”, “completely deluded” and “very unwell”. This psychological assessment was unknown to the prison authorities until many years later.

Stephen Egan’s move to Mountjoy on July 29th, 2006, was for purely operational reasons, and no consideration was given at any stage to his mental state or the threat he posed to others.

The medical doctors in Mountjoy did not know of his arrival there and therefore did not ensure he was kept on his anti-psychotic medication, nor were the prison officers aware of the danger of placing Gary Douch and others in a cell with him.

Declared dead
On the morning of August 1st, 2006, the prison officers found Gary Douch under a pile of duvets, with a sheet over his face. He was declared dead shortly afterwards at the Mater hospital. The postmortem showed he had been "violently assaulted and then his face was smeared with faeces". (In 2009 Stephen Egan was found not guilty of murder but guilty of manslaughter on the grounds of diminished responsibility.)

The report made several damning findings about the prison service: “Record-keeping . . . was inconsistent, incomplete and unreliable to a degree which seriously compromised (Stephen Egan’s treatment)”; there was a “reckless disregard in selecting him for transfer to Mountjoy for the health and safety of the staff [in Mountjoy]”; “overcrowding in Mountjoy prison completely undermined the ability of the prison to respond (to Gary Douch’s request for protection)”; conditions in the holding cell were “appalling and unacceptable”; the Mountjoy regime that operated at the time of his death “was inept, dysfunctional and showed a reckless disregard of the safety and needs of both prisoners and staff”; “a culture of non-compliance with regulations, protocols, guidance and orders was tolerated by Mountjoy prison”; “the problem of overcrowding in Irish prisons has not abated, but has in fact grown to an unprecedented extent”.

Our political system is also dysfunctional. There is no meaningful accountability to the Oireachtas by the executive arm of government; politics is only about which crowd gets the ministerial perks and thrills and which marketing strategy can best achieve that; for individual TDs, politics is mainly (all?) about retaining their seat.

Our legal system ditto. The hopelessly unequal access to the courts seems not to bother the judiciary at all. There is a legal culture that seems almost designed to exclude ordinary people via arcane procedures, and dense, complicated and at times foreign language.

Our health system would be better were it merely dysfunctional.

Meanwhile, perhaps the worst instance of carelessness and indifference in our police force was its “investigation” into the murder of 33 people in Dublin and Monaghan 40 years ago.

Maybe a mistake was made 100 years ago when the British parliament promised us home rule.