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Andrew Gearns with his brother Evan.
Andrew Gearns

Coroner says unresolved IT glitch a 'serious issue for entire prison system' at Cork man's inquest

The inquest of Andrew Gearns continued today.

A CORONER HAS warned that an unresolved IT glitch which may have contributed to the death of a Cork man in prison three years ago may be a “serious issues for the entire prison system”.

Coroner Philip Comyn made the remarks at a hearing into the death of Andrew Gearns, 29, a father of two from Model Farm Road.

The deceased died at Cork University Hospital on 7 October 2020, nine days after he made a suicide attempt in his cell, after being brought into prison to serve a short sentence.

His brother, Even Gearns, claimed that his brother’s life “could have been saved” had he been placed under special observation.

Evan Gearns was speaking after a coroner’s inquest today heard that his brother was not placed under special observation at the prison, despite multiple prison staff being aware that he was suffering delusions.

“New protocols need to be brought in so real changes are made to how the mental health of prisoners is monitored, so further deaths like Andrew’s are avoided,” Evan Gearns told The Journal. 

Evan claimed that his family had to “fight” to get the inquest, and that they also had to fight to get the report from the Office of the Inspector of Prisons, which is separate to the inquest, and made key recommendations to the Irish Prison Service.

“We received the report 48 hours before the inquest began. It is a disgrace. We were promised that we would receive it earlier. We are hoping that we will get clearer answers from the inquest and that real changes can be made to how prisoners are cared for,” he said. 

Before Andrew Gearns’ arrest in 2020, the record of the deceased showed that he told a nurse when he was arrested in 2018 that he had attempted suicide while in Garda custody. 

Despite having been placed under special observation in 2018 as a result, he was not deemed to be at a high risk in 2020 and he was not placed under special observation.

Aideen Gearns, his mother, told the court that her son was in a “bad place” when he was brought into custody in September 2020, as since 2016 he had developed a drug misuse problem following a car crash, which started with an addiction to medication. 

His inquest, in front of Comyn and a jury of four men and two women, heard today that due to Covid-19 restrictions in place at the time, the deceased was put into an isolated cell in Cork Prison, and that he would have had “minimal interactions” people, and that he rarely left his cell. 

Comyn also told the inquest it is “highly concerning” that an IT glitch which was deemed to have contributed to the tragedy, has still not been resolved three years on and that it represents a “serious issue for the entire prison system”.

System error 

The inquest heard that a “technical glitch” in the Irish Prison Service’s (IPS) systems caused information from a previous committal interview conducted with the deceased following his 2018 arrest to appear on the record of his 2020 committal interview. 

The committal interview in 2020 determined that the deceased should be put in a general prison population cell, rather than a special observation cell for high-risk prisoners, who may be a danger to themselves, staff, or other prisoners.

Such prisoners are checked on by prison officers every fifteen minutes. 

The inquest heard that the inaccuracies caused by this glitch led to incorrect information going on the record of the deceased.

This included information about the medication he was taking, whether he had been referred for psychiatric treatment before, and information which he the IPS in 2018 about a previous suicide attempt.

The nursing manager for the prison, Enda Kelly, told the inquest that this technical issue was discovered by IPS as a result of the case, and that the issue is ongoing. 

The coroner told the inquest that is “highly concerning” that three years on, this issue has still not been resolved, and that it represents a “serious issue for the entire prison system”.

‘Easily reassured’

A nurse who assessed the deceased in 2020 told the inquest that the deceased was “easily reassured” that he had no wounds from an incident in Cork before his arrest, and that she scheduled him to see a GP the next day, and for the next available psychiatric clinic. 

She also stated that she did not believe the deceased to be a risk to himself at that time

Counsel for the IPS, Ellen O’ Driscoll, asked the nurse if she had made an “incorrect call” in not placing the deceased under special observation following his committal interview.

However, the nurse said that the GP who was set to see him the next day would have been able to move the deceased to a special observation cell. 

She also said the doctor did not view the deceased as being at risk of self-harm or suicide following his assessment. 

The mother of the deceased, Aideen Gearns, also appeared before the inquest and told the court that the deceased was in a “bad place” when he was taken into Garda custody, that he was on “tablets and heroin” and living with her at the time. 

She said that when Gardaí came to arrest the deceased, they reassured her that they would “look after him”.

Aideen Gearns said that she spoke to her son a couple of days later and that he seemed fine, but said that he may have Covid-19.

On Monday 29 September, the day of the suicide attempt, Aideen Gearns said she had a six-minute phone call with her son at around 12pm.

She said that the deceased told her that prison officers had taken him to Blackpool, and that he was stabbed, and that he then went to Mayfield for “a cup of tea”. 

She said the deceased also told her that he had not used his daily call to phone his long time ex-partner and the mother of his children, as he did on other occasions, as she had been in the prison “all night” with him. 

Aideen Gearns became tearful as she told the inquest that she was worried that she wouldn’t be able to get her son off the phone, so that she could ring the prison and tell them that something was wrong, and that he was not making any sense. 

“I was really worried,” she said. 

When she got off the phone to her son, she told the inquest that she rang the prison straight away and was put through to a nurse, who she said told her that staff were aware of her son’s delusional state, and that they would “keep a closer eye on him”.

When questioned by counsel for the IPS, Aideen Gearns accepted that her son was checked by prison staff 13 times between her call and the time he was found 4.50pm, when a code red alert was issued.


Evan Gearns also told the inquest that when his brother was taken into custody, he and his sister assured their mother that he was “in the best place”. 

However, he said that he  had no contact with his brother when he was in prison. 

He told the inquest that his brother had become more “aggressive” and his life had gotten “darker”, since he started to have addiction problems in 2016 and lost his job, and his 17-year relationship had ended. 

Evan Gearns said that he believed his brother was ready to turn his life around before he went into prison in 2020. 

“He wanted to help himself. He didn’t want to be on drugs, he just wanted help,” he said. 

He added that it had been his hope that his brother would get through his short stint in prison and come out ready to turn his life around.

Prison Officer Paul Cleary, who was in charge on the day that the deceased attempted suicide, said he checked his cell a number of times that day.

He told the inquest that at 4.50pm he lifted the hatch to conduct a check, and the cell was dark, but he could make out that the deceased was unconscious. 

Cleary said he alerted medical staff, and went into the cell to help, before stepping away when medical staff arrived.

He said that he was not aware that the deceased had told a prison nurse that he had attempted suicide while in custody.

The inquest will continue tomorrow.

Need help? Support is available:

  • Samaritans – 116 123 or email
  • Pieta House – 1800 247 247 or email (suicide, self-harm)
  • Aware – 1800 80 48 48 (depression, anxiety)
  • Teen-Line Ireland – 1800 833 634 (for ages 13 to 18)
  • Childline – 1800 66 66 66 (for under 18s)
  • SpunOut – 01 675 3554 or email