A prisoner hanged himself within hours of entering HMP Cardiff after authorities failed to tell the jail about his recent suicide attempts. Prison staff did not know John O’Driscoll, 35, had twice overdosed on tablets in the days before he took his own life.
The newly-released prisons ombudsman report states Mr O’Driscoll was handed a 16-month jail term in March 2021 for burglary. “He had spent several periods in prison and had a history of substance misuse and mental ill health,” wrote acting ombudsman Kimberley Bingham. “In April 2021, he told staff he had attempted suicide and was monitored under suicide and self-harm prevention procedures.”
In December that year he was released on licence to the Mandeville House approved premises in Riverside. While there he reported suicidal thoughts to staff, who monitored him under suicide prevention protocols. He was briefly hospitalised in late December after taking a large quantity of illegally obtained anxiety tablets.
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Then, in the early hours of December 29, he again swallowed a large quantity of anxiety tablets. Staff called an ambulance and when paramedics arrived he was aggressive. Staff at the approved premises and probation service decided to recall Mr O’Driscoll to prison.
That afternoon Mr O’Driscoll was taken to Cardiff Bay police station. But when the custody sergeant completed the person escort record for his transfer to prison, the suicide and self-harm risk assessment section was left blank, with no mention of his recent self-harm. Mr O’Driscoll arrived at HMP Cardiff shortly after 4pm on December 29 and when prison staff reviewed the paperwork they found “no immediate safeguarding concerns”. They put no additional monitoring in place.
Officers took Mr O’Driscoll to his cell shortly after 6pm. At 9.04pm, an officer looked through Mr O’Driscoll’s cell observation panel and saw he had hanged himself. Healthcare staff could not find a pulse and paramedics confirmed his death shortly afterwards.
Ms Bingham pointed to failings by both the probation service and police. She wrote: “When probation staff completed a licence recall notification document for Mr O’Driscoll, they did not share information on his recent suicidal thoughts or self-harm with the prison. This, coupled with the same omission in the person escort record completed by the police, meant prison staff were unaware of Mr O’Driscoll’s recent overdoses when they completed initial suicide and self-harm risk assessments.
“Had [prison staff] known about the circumstances that led up to his recall, they might have put additional monitoring in place to safeguard him… No additional safeguarding measures were put in place on his first night. In response to early learning from Mr O’Driscoll’s death, Wales Prison and Probation Service developed guidance that aims to improve the communication of urgent risk information between the probation and prison services at the point of recall.”
The ombudsman also aired concern over the lack of documentation by prison staff. She wrote: “Staff involved in the emergency response did not complete written statements following the incident. The lack of body-worn camera footage and written statements limited our ability to investigate the staff response.”
You can contact the Samaritans for non-judgmental advice 24/7, 365 days a year, by calling 116 123 or by emailing jo@samaritans.org.
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