Verdict of misadventure recorded in death of prisoner

Seán McCárthaigh

A verdict of death by misadventure has been recorded in the death of a prisoner with a history of mental illness after he had been physically restrained by staff at Cloverhill Prison in Dublin six years ago.

An inquest into the death of Ivan Rosney (36) heard evidence from an expert witness that prison officers involved in the fatal incident had diverged in several different ways from an Irish Prison Service manual on how to control difficult prisoners.

They included deviating from an instruction that prisoners should never be held in a prone (face down) position for any longer than absolutely necessary.

The coroner, Myra Cullinane, said she was struck during the three-day inquest by the number of prison staff who did not understand the word “prone.”

Rosney, a father of four from Ferbane, Co Offaly, died on September 28th 2020, at Tallaght University Hospital where he had been brought after becoming unwell while being carried face down with a spit hood over his face.

The fatal incident occurred as prison staff were attempting to return Rosney to his cell after he resisted being brought to a booth within Cloverhill for a remote court appearance when he was restrained with handcuffs, leg restraints and a spit hood.

Rosney had been remanded to the prison a few days earlier after he was arrested following an incident in his father’s house when he became physically aggressive.

A postmortem concluded that Rosney’s death was due to a terminal cardiac arrhythmia (irregular heartbeat) against a background of a man with an enlarged heart and elevated body mass index who was being restrained in a prone position.

The inquest heard the deceased weighed 133kg (approximately 21 stone) which classified him as “morbidly obese.”

In addition to recording a verdict of death by misadventure, a jury of four men and three women also made a number of recommendations which had been suggested by legal representatives of the Rosney family.

They included that all prison officers should be fully trained in control and restraints techniques and their associated risks and dangers.

The jury also called for the IPS training manual to define “in explicit terms” what was meant by the prone position.

Offering her condolences to the deceased’s family, Dr Cullinane expressed hope that “something of value may come out of this tragic loss.”

The former governor of Cloverhill, Tony Harris, who now oversees operations within the IPS, said improvements had been introduced in recent years in relation to training and CCTV systems.

Harris pointed out that there are 354 IPS staff who are highly trained in control and restraint methods, but said it was unfortunate that such specialists were not always available in spontaneous situations.

He noted that 84% of all prisoners were considered to have some type of mental health issue, which he described as “an astonishing figure.”

However, he accepted that the IPS had to get better at informing prison staff about specific instructions, which he labelled the “Do Nots”

Harris said there was also an absolute need to come up with a system for conveying large-sized prisoners in a safe fashion.

He told the coroner that the IPS would also soon be issuing a tender for body-worn cameras to be used by prison officers.

Harris said the changes had been introduced to avoid tragic situations in the future, although he acknowledged it might be “cold comfort to a grieving family.”

A control and restraint instructor with the Scottish Prison Service, Grant Wilson, who reviewed CCTV footage of the fatal incident, told the inquest that he had identified seven instances where prison staff appeared to have deviated from instructions contained in an IPS manual.

Wilson said prison officers could have placed Mr Rosney on his side and back as his hands and legs had already been restrained.

A preliminary hearing of the inquest in June 2023 heard that DPP had directed that no criminal prosecution should arise from the circumstances of Rosney’s death on foot of a Garda investigation.

Outlining the details of a postmortem on Rosney’s body, the chief State pathologist, Linda Mulligan, gave evidence that his ability to breathe would have been affected by being in a prone position which would have also placed a strain on his heart.

Prof Mulligan told a sitting of Dublin District Coroner’s Court on Thursday that an antipsychotic medication prescribed to Rosney, Olanzapine, was also a contributory factor in his death.

She explained the drug was associated with an increased risk of sudden death because of its effect on the heart.

The pathologist said bruising found across several parts of the deceased’s body was consistent with his struggle with prison officers.

The postmortem confirmed he had no skull fractures or neck injuries, while there was no evidence he had experienced any lack of oxygen to his body.

In other evidence, a retired work and training officer in Cloverhill, Andy Byrne, acknowledged that the prisoner should never have been carried in a prone position but stressed: “We had no alternative on the day.”

The inquest heard Byrne had taken over supervising efforts to restrain the prisoner because of his experience as a control and restraint instructor.

In reply to questions from Dr Cullinane, the witness accepted that the IPS manual stated that supervisors should not get physically involved with restraining a prisoner.

Byrne said it was unfortunate, but they sometimes had to “step in” to a situation.

The witness said he first became aware something was wrong when another prisoner officer had alerted him that the prisoner had turned blue when he immediately began chest compressions on Mr Rosney.

He told counsel for the Rosney family, Gabriel Gavigan SC, that he had noticed a small amount of blood on the prisoner after taking off his spit hood on a stairwell.

Byrne said it was like “someone who bit their lip” but stressed that the amount of blood was “in no way excessive.”

He admitted asking for a nurse to be present for when Rosney had been returned to his landing as standard practice rather than due to concern about the prisoner’s condition.

Asked by counsel for the Irish Prison Service, Simon Mills SC, if the incident involving Mr Rosney was unusual and exceptional, Mr Byrne replied: “I believe so.”

Welcoming the verdict, the deceased’s father, Des Rosney, said it was “what I suspected from Day 1 that Ivan was carried in the prone position.”

Rosney said he was also happy that the IPS had acknowledged that what happened was wrong.

“It was the great hope I had when Ivan was being sent back to prison. I had absolutely no fear whatsoever as I had seen the way he came back from prison before when he was a new man because he had received the treatment he needed,” he added.

Earlier this year, the Office of the Inspector of Prisons expressed “deep reservations” about the manner in which Mr Rosney was restrained as well as about the extent of both external and internal injuries to his body.

A report by the OIP, which was published last February, said it appeared prison officers had not fully complied with correct control and restraint procedures operated by the IPS, including a failure to seek healthcare advice when Rosney showed signs of distress including blood coming from his nose and mouth.

The OIP report, which was not referenced during the inquest, called on the IPS to review its control and restraint training programme to ensure prison staff were aware of the risks and dangers involved in restraining prisoners.

The OIP also recommended that the advice of prison healthcare staff should be sought before any control and restraint techniques are applied to a prisoner with mental health issues who is not being cooperative.

In response to the OIP report, the IPS said it was satisfied that its current control and restraint programme was “sufficient”, while its training manual had been reviewed and updated in 2023.

The IPS rejected a recommendation that prison staff should have to pass a technical and written examination on control and restraint procedures.