Inmate found dead after prison officers take 30 minutes to respond to alarm call

Cork Prison

An inmate was found dead at Cork Prison after it took officers 30 minutes to respond to an emergency alarm from his cell because the volume on the system had been manually reduced to its minimum level.

Prison staff in a nearby control room also failed to see a flashing light outside the man’s cell indicating an emergency because notices placed on a window were obscuring their view.

The Office of the Inspector of Prisons (OiP) conducted an investigation into the death of the 54-year-old inmate and identified a number of “very high risk” systemic concerns that required immediate intervention.

Investigators found that a prison officer working on the morning of October 2, 2021 had entered in a log that he had “patrolled the landings for the duration of duty checking all offenders at regular intervals finding all correct”.

However, CCTV footage showed that he did not conduct checks. He subsequently said that he had written that entry before he could carry out the checks because a medical emergency had occurred.

When the prisoners were due to be let out of their cells for breakfast, there was an insufficient number of officers available, so a “staggered unlock” was ordered.

At 9:04am, the prisoner pressed the regular call alarm in his cell and, three seconds later, pressed the emergency call alarm.

At this time, an officer was “almost adjacent” to his cell but did not see the alarm light outside the door because he was looking upwards.

The system should also have triggered an alarm in the control room, but the officer located there did not hear any sound and did not have a clear view of the light outside the cell.

The officers waited between 30 and 35 minutes for more staff to arrive so they could go ahead with the process of unlocking cells and allowing inmates to go for breakfast.

At 9:35am, staff began unlocking cells and finally saw the light. One of the officers immediately opened the door and found the inmate in a seated position on the floor, slumped against the lower bunk bed.

He called for medical assistance and placed him in a prone position on the floor. Nursing staff arrived at the scene and observed that the man was warm and clammy, and had no palpable pulse.

They attempted to resuscitate him for 45 minutes, after which point he was pronounced dead at 10:26am.

Investigators from the OiP visited the prison and found that the volume on the emergency alarm had been manually reduced to the minimum level and made only a “faint buzz” when activated.

Following the man’s death, the governor immediately ordered that the option of reducing the volume on alarms be removed, and required that the call system be checked daily.

However, a follow-up inspection at Cork Prison found that the view of most cell doors from the control room was still obscured by posters or notices on the glass window.

The OiP made a total of eight recommendations following the investigation, including that the volume control on the emergency system be locked, that officers continuously observe the landing to which they are assigned, and that the location of call lights outside cells be reconsidered.

The cause of the man’s death is a matter for the coroner.

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