A report into the death of a man discovered in a cell just four hours after entering Cork Prison found he was only checked on five times instead of 14 as set down in procedures.
The report was issued by the Inspector of Prisons, Helen Casey, into the death of an unnamed 45-year-old remand prisoner who was found dead in his cell in the prison on January 29.
The man, who was married and had two children, was in the prison for just over four hours before he was found dead with a ligature around his neck.
The report recommends that a structure should be developed by the Irish Prison Service to ensure that standard operating features are known to all prison staff.
The man had been assigned a cell on B1 landing at 3.35pm that afternoon and was found unresponsive at 7pm. He was pronounced dead at the prison after efforts to revive him failed.
As a new prisoner, he had been placed on the Special Observation list, meaning that he should be checked every 15 minutes.
However, Ms Casey's report stated: “Records show that the deceased's cell was checked on five occasions from 15.45 to 19.02. If the terms of the SOP (Standard Operating Procedure) were complied with, 14 checks should have been conducted.”
She said that the prison staff responded quickly when the man was found unresponsive. But she said: “The Irish Prison Service should develop an appropriate management and governance structure to ensure that Standard Operating Procedures are (a) known to all staff and (b) implemented at all times.”
The report added: “Supervision by Line Managers is a vital part of implementing policy. The Irish Prison Service should review the level and quality of training to satisfy itself that it is sufficient to equip supervisory grades with the necessary skills to carry out their function.”
And she concluded: “Where procedures are breached, appropriate disciplinary investigation should be conducted and those who failed to carry out their duties be held to account.” The death will be brought before the Coroner's Court to establish the cause of death.