A man suffering with a psychiatric condition died in his cell at Limerick Prison after a "systems failure, in relation to his incarceration", his inquest has heard.
Sean Hayes Barrett died six days before his 32nd birthday, while he was being held on remand at the jail, between April 16th and May 5th, 2017.
Prior to his incarceration, he had spent five weeks in a psychiatric ward at University Hospital Limerick.
He was on medication to treat signs of suicidal ideation, but it was accepted that while he was being held in prison he was not given adequate doses of his medication.
He had no record of being arrested prior to this incarceration and he no previous convictions. His family said afterwards they had still not been told why he had been arrested.
He was found dead alone in his cell on May 5th. A handwritten note was found in the cell.
A number of prison officers, who were on duty at the jail on the night, gave evidence they had no prior knowledge of Mr Hayes Barrett’s medical history. They said they were “not aware” he was on a list of prisoners for special observation which as part of the prison’s own protocols, require they be checked every fifteen minutes.
The inquest heard Mr Hayes Barrett should have been checked 36 times, but he was checked on only nine occasions.
He had complained to a loved one during a recorded telephone call made from the prison, that his mental health was suffering because he was being kept in a cell on his own.
“It’s too hard, I’m not able for the isolation, the isolation is too hard on me,” he said.
Investigations were subsequently carried out by gardaí, the Inspector of Prisons, and by Limerick Prison into his death.
Governor of Limerick Prison, Mark Kennedy said CCTV footage from the jail, which was requested by the Inspector of Prisons had "disappeared", most likely due to human error, when it was being transferred "by our IT department" to the Inspector's office.
‘Diverted’
He agreed prison officers were not aware Mr Hayes Barrett was a special obs prisoner. He said the prison’s “manual system” at the time whereby a list of special obs prisoners would be printed out and left for staff on a sheet of paper “wasn’t robust”.
“We weren’t 100 per cent that the officers on the night got the up to date special obs list,” Mr Kennedy said.
Prison protocols at the time meant it was “physically impossible” for staff to make all their checks and deal with any other emergency situations that could arise within the prison population, he said.
Staff were “diverted” to another serious injury on the night.
“We didn’t abide by our own protocols. Our own protocols were that he needed to be checked every fifteen minutes and that didn’t happen,” Mr Kennedy said.
“It is fair to say this case was a landmark case, and, as a result of Sean’s death the whole system has changed throughout the prison service.”
Coroner, John McNamara, recorded an open verdict.
He said that “under Article Two of the European Convention on Human Rights, the state has a positive duty to prevent deaths where possible, and it appears to me there were system failures in respect of Sean Hayes’s incarceration”.
Mr McNamara said the nature of Sean’s death “on the face of it would imply that it was a suicide” but he added, “having considered the matter and taken into account the system failures, I’m not happy to record a verdict of suicide”.
The family's solicitor, Jerry Twomey reading a statement on behalf of the Hayes Barrett family afterwards said: "Sean had never been in any trouble whatsoever in his life. To this day he's never been convicted of a single criminal offence.
“Despite this, Sean found himself incarcerated in Limerick Prison where after being deprived of his correct and prescribed medication, alone and vulnerable, he took his own life.
“Today the coroner recorded an open verdict. The coroner recognised the many shortcomings of the prison service while Sean was in their care.
“We are satisfied with the open verdict in Sean’s death and we are happy to hear that many others are safer as a result in the changes made, since, and because of Sean’s loss. We will miss and love Sean forever.”