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Man died in court holding cell after requesting prescribed medication that had been stored in locker

A new report examines the circumstances that led to the man’s death.

A MAN WITH a health condition collapsed in a court holding cell and later died minutes after asking a prison officer for his medication which had been stored in a locker, according to a new report.

The report from the Office of the Inspector of Prisons (OIP) examines the circumstances surrounding the death of a 42-year-old man while he was in the temporary custody of the Irish Prison Service at the Criminal Courts of Justice (CCJ) in Dublin on 8 December, 2021.

According to the report, the man – known as Mr X – had come to the attention of gardaí following a “minor traffic incident”. Gardaí checked the PULSE system following this and discovered the man had an outstanding bench warrant for failure to appear before the Courts in April 2010.

He was arrested by appointment at Clondalkin Garda Station on the morning of 8 December 2021. Mr X’s partner told the OIP that in the months preceding this he had been rushed to hospital with a cardiac related issue.

According to his partner, Mr X had provided gardaí with details of his health issues including a list of prescribed medication and informed them that he had to take a self-administered injection at specific times during the day. He had the medication he required in his possession when he was arrested.

Mr X was taken to the CCJ and transferred into the the care of the IPS. He was placed in a holding cell. According to the report, one of the prison officers responded to a cell call alarm from Mr X, who told them that he had to  take a self-administered injection at 11:00.

The officer said he was not authorised to administer medication and would inform a nurse. Soon after, Mr X collapsed in his cell, and the prisoner officer heard a loud bang.

The officer said they found Mr. X face down on the cell floor with another prisoner hunched over him. Officers reported putting Mr. X in the recovery position and described him as being “short of breath, visibly perspiring and red in the face”.

A healthcare assistant arrived and helped officers in providing CPR. An officer reported that he received Mr X’s medication from the locker, but that it was not administered. 

Resuscitation attempts continued before Mr X was taken to the Mater Hospital. He was later pronounced dead.


The report found that while gardaí had been provided with details of Mr. X’s medical conditions and medication prescribed to treat them, “this level of detail was not provided to the IPS during the handover process”.

As Mr X was being handed over to the custody of the IPS, the report said four medications that he had been prescribed were listed, however “there was no specific detail relating to the time this medication was to be taken, just the name of the medication, one of which was an antibiotic and another was an injection”

The report also noted that Mr X’s temperature was taken on arrival at the CCJ and was recorded at 34.6 which was below the normal range. The report stated that this “should have raised concerns and warranted further questioning regarding his general health and medication”.

“As the person was being received from the custody of AGS and not know to the IPS healthcare personnel, the advice of a qualified nurse or doctor should, in the circumstances, have been sought and their advice recorded in an official record,” the report concludes.

The OIP makes four recommendations in the report, including:

  • that a Person Escort Record should be introduced and completed for every movement of a person into or out of prison custody;
  • that the IPS should assign a nurse to the Criminal Court of Justice;
  • that the IPS should introduce a ‘Personal Belongings Record’;
  • and that a Standard Operating Procedure should be developed by the IPS to provide healthcare personnel with clear guidance for people who are in temporary custody after recently undergoing healthcare issues.

A second investigation into the incident is being carried out by GSOC.

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