Over the past two weeks, Joseph’s parents Tommy and Sarah have listened patiently and with dignity to a litany of personal, systematic and institutional failings, which collectively combined to present a series of preventable failings which contributed to Joseph’s death.


Joseph’s parents seek to thank the Coroner, Patrick McGurgan and the jury for their attention, patience and considered verdict.


Notwithstanding the exposure of the truth over the duration of this inquest, this has been a painful and traumatic process.  Joseph’s death was entirely preventable. At every stage of his committal to Hydebank Wood, over a period of just 2 hours, there were failings. Joseph’s parents want to ensure that systems are put in place to ensure that no other young person is exposed to the dangerous failings that their beloved son was exposed to.


23 people have died in custody since Joseph’s death and a further 23 have died within a fortnight of their release.  The system is broken and requires emergency attention before any other young people die.  To this end, Joseph’s parents will be seeking an urgent meeting with the Minister of Justice to discuss these findings and to ensure that their much loved sons death is not reduced to a faceless statistic.




Sunday 7th April 2013 Arrested at 1945 and was admitted to Musgrave custody suite at 1955.  He was assessed as a medium risk to himself and others, and the custody record notes that he stated that he was suffering from depression and felt suicidal.  The Care Plan decided upon, was that he was to be assessed by an FMO, with constant CCTV, with a level 3 observation of ‘constant observation.’  He was seen by a doctor employed by the police at  2105 who considered that he was fit for detention but not fit for interview.


Monday 8th April 2013 He was not fit for interview until the Monday, whereon he was charged to appear at Belfast Magistrates Court on Tuesday 9th April 2013.  He was subject to constant supervision and review whilst in PSNI custody.


Tuesday 9th April 2013 Remanded to appear at Laganside court and then to Hydebank.


1355    Arrives at Hydebank He was booked in and a Reception Officer interviewed Joseph as part of the Committal Process.  Although the Reception Officer claimed to the Ombudsman in interview that he had read documentation from the police station (forms PACE 15 and PACE 16) that confirmed in writing that Joseph had was suicidal whilst in police custody, Stevenson was forced to admit when giving evidence at the Inquest that he had not read the forms.  He said that ‘he tended to rely on his own observations of a new committal rather than what is written on PACE 15 or PACE 16 forms’ and further confirmed that he had received no training in suicide awareness.


1427    Arrives on committal landing The Officer Joseph encountered at this point had no experience or training in how to conduct a Committal interview. Although he received the PACE 15 and PACE 16 confirming that Joseph had suicidal ideations, he did not read them but left them on a desk. Neither did he pass them on to Healthcare staff as he ought to have done.


1435    Committal Book signed off Without considering the PACE forms or a proper handover from Reception the landing officer was unaware of Joseph’s vulnerability.


This same landing officer then signed off the committal book recommending that ‘Mr Rainey be monitored on hourly observations, the maximum interval under which all new committals are observed for a minimum of 24 hours.


In his evidence the officer admitted that, had he known what was written on the forms, he would have opened a SPAR (Supporting Prisoners at Risk) document in relation to Joseph. We know that the police had Joseph on observations every 30 minutes, in a CCTV cell, yet despite Joseph’s self-report of suicidal ideations in the police station he was lodged in a cell with the absolute maximum intervals between observations.


1556 – 1604    Joseph tells nurse about suicidal ideations


Over an hour after arriving on the committal landing, Joseph was seen by the nurse. The nurse was unaware of the contents of the PACE forms, which indicated suicidal and depression markers.


Furthermore, the most shocking aspect of the entire series of failures is revealed at this stage.  Notwithstanding the failure to ensure that appropriate staff were in receipt of the PACE forms, Joseph directly reported to the nurse ‘Actually I might hang myself with my bed sheets’.  He then indicated that he might not but he was ‘gonna think about it’.


In her evidence the Nurse indicated that her decision to open a SPAR on Joseph was a ‘borderline’ however, had she seen the PACE documents which established that Joseph had a similar conversation with a police doctor 24 hours earlier, it would not have been been borderline.


In addition, the nurse indicated in her evidence that she had not received any training in suicide prevention, she was not aware of the NIPS Suicide and Self Harm policy or the Standard Operating Procedure, and that despite requesting Applied Suicide and Intervention Skills Training, she had not yet received it.’


The NIPS Suicide and Self Harm Prevention policy states that the initiator of the SPAR should remain on duty until the Keep Safe is completed.  Both the senior officer and nurse said they were unaware of this, and it differs from the instructions found on the front page. In any event, the nurse left the prison and the keep safe plan was conducted by an officer with no previous knowledge of Joseph.


1704 – 1706 – in the course of a ‘Keep Safe interview which lasted approximately 70 seconds  Senior Officer Denvir claimed to PrONI to have ‘dismissed’ the concerns of the nurse which he said were ‘neither here nor there’ and concluded that Joseph was not suicidal. He said that he gave Mr Rainey the option of whether he wanted hourly, half hourly or 15 minute observation intervals. This was not a decision that should have up for discussion with Joseph. What ought to have been a multi disciplinary meeting to identify the underlying reasons for Joseph’s vulnerability was a 1 minute conversation that served only to dismiss the comments that Joseph made to the nurse and, effectively, increase his vulnerability. Hourly observations for a suicidal person, were meaningless. The officer made the decision absent any consideration of the documents that had come from the police station with Joseph. Had he considered those documents, it was his evidence that Joseph would have been on 15 minute observations.


1740    Joseph asked for Samaritan phone number.  This fact is exceptionally distressing in the overall context of the series of failings.  Notwithstanding the fact that Joseph asked for the Samaritans phone number at 1740 he was not able to make the phone call for a further 25 minutes as prison staff didn’t have the PIN for the phone number.


1805 – 1814    After PIN found, Joseph phones the Samaritans for 9 minutes.  25 minutes after asking for the Samaritans phone number, Joseph phoned the helpline and spoke for 9 minutes.  The report seems to attempt to assert that the call was not intended as a serious one, with unattributed quotes from anonymous prisoners, however the pattern of the day is now depressingly abject.


1840    Joseph observed sitting at a desk writing a letter     


In the context of:

  1. PACE 16 form recording suicidal ideations
  2. A direct self-report of a threat to commit suicide less than three hours previously
  3. A request for the Samaritans phone number and a 9 minute phone call to them, less than half an hour previously


The sight of Joseph sitting composing a letter, having expressed suicidal thoughts and spoken to the Samaritans on his first night post admission should have rung loud alarm bells amongst staff.  It didn’t.  With the litany of failures already recited, within 3 ½ hours Joseph would be found hanging.


In a particularly distressing piece of evidence, one officer indicated that he may have made up an entry on Joseph’s observation log that did not in fact take place.


Thereafter the failures continued. Not a single officer on night duty knew, or made themselves aware of why Joseph was on a SPAR or what his vulnerability was. No one knew, nor was told, that Joseph had expressed that he might hang himself. In consequence, no one even asked Joseph how he was feeling or if he was OK. This basic lack of human concern and interaction is very difficult for Joseph’s family to comprehend.




The litany of depressing failures laid out over the last two weeks are so clear as to be undeniable.


Personal Failings

There are explicit individual failings by specific personnel,

  1. The Reception Officer,
  2. The Committal Landing Officer,
  3. The Officer conducting the Healthcare Interview
  4. The senior officer who should have seen through the SPAR and also
  5. The nurse.


Personnel at various stages assert that they had no experience, had not conducted committals before, had no training or awareness of forms PACE16, or suicide training and indeed had requested training and had not been given it. The catalogue of failures is repeated and catastrophic, which considered in summary demonstrate a complete disregard for process and standards.


Systemic Failings


The system that permitted an officer to “rely on his own observations of a new committal rather than what was written on PACE 15 or 16 forms.” is a failed system.


It is a failed system that permits a nurse to confirm that she

  • “had not received any training in suicide prevention”,
  • “was not aware of the NIPS Suicide and Self Harm policy”
  • “that despite requesting Applied Suicide and Intervention Skills Training, she had not yet received it”


Joseph’s parents wonder where was the check list for mood assessment.  Joseph’s behaviour at a minimum was erratic, with mood swings etc. There should have been systems in place, to accurately assess and manage this.  No such system was in place.


Joseph’s parents are concerned and exercised and rightly enquire as to who is the senior management responsible for ensuring that staff in such key positions are appropriately trained?


Institutional Failings


Over time, the Prison Service has failed to deal with previous examinations and criticisms many of which the jury heard about. Recommendations in relation to consideration of police documentation and recommendations in relation to the proper application of NIPS’ own policys and procedures had been repeatedly made by PrONI in relation to no fewer than six other deaths over a 5 year period. Each represented an opportunity to change. Each opportunity was repeatedly missed.