Inquest Jury Concludes Prison Failings Contributed to Death in Custody of Jonathon Stewart in Maghaberry 17th May 2017

 

PRESS RELEASE

JURY VERDICT IN INQUEST INTO THE DEATH OF JONATHON STEWART IN MAGHABERRY JAIL ON 17^TH MAY 1997

VERDICT DELIVERED 20^TH JUNE 2023

ISSUED BY HARTE COYLE COLLINS ON 21^ST JUNE 2023

A jury sitting in an inquest into the circumstances of the death of Mr Jonathon Stewart in Maghaberry jail on the 17^{th of} May 2017 concluded yesterday that failings by the Northern Ireland Prison Service contributed to his death.

Jonathon Stewart, 38 and a trainee chef was from Craigavon and a remand prisoner at Maghaberry jail who was found in Cell 15 of Lagan House at 2.30 am on the 17^{th of} May 2017 with incisions to his neck and left arm.  The inquest into the circumstances of his death at Newry Courthouse ran from 12^th June until yesterday 20^th June 2023.  The inquest heard evidence from Mr Stewart’s family (his father and sister), prison Governors, prison officers, medical personnel attached to the prison, prison inmates and experts.  Evidence was provided by some of the initial investigating police.  Expert evidence included evidence from a pathologist and a blood pattern expert commissioned by the family.

After hearing the 6 days of evidence the Coroner Ms. Toal summed up the evidence to the jury yesterday.  The jury deliberated on the verdict throughout the afternoon.  The inquest jury could not agree that Jonathon Stewart intended to take his own life.  The verdict was recorded yesterday is the anatomical cause of death resulting from incisions to his neck.  Mr Stewart had no history of mental health problems and was not being treated as a vulnerable remand prisoner by Northern Ireland Prison Service at the time of his death.

During the inquest issues raised on behalf of the next of kin included the lack of CCTV on Landing 6 in Lagan House where Jonathon had been moved a few days before his death, failure of prison officers to carry out the necessary night checks in a timely manner, insufficient prison staffing levels, and prison officers working 24 hour shifts.

The legal team for the family also raised questions about the adequacy of the police investigation which resulted in the blades used to inflict the wounds never being located despite the single occupancy cell being locked.  Police, photography, CSI, and prison staff were all questioned about the failure to find the blades and the failure to use metal detectors or other methods to search for them. The drains in the sink and toilet were not checked for blades.  Medical kits used on Mr Stewart which were disposed of in the corridor were not checked for the missing blades.  Mr Stewart’s clothes were not retained for medical examination. No explanation for the absence of the blades has ever been provided to the family by PSNI or NIPS.

During the course of the 6 days of evidence the legal team representing the family (Karen Quinlivan KC, Sarah O Reilly BL, and Patricia Coyle, solicitor) directed questions to the witnesses the highlighting of failings in the prison system which contributed to the death of Mr Stewart and the problems with the police investigation.

The inquest jury concluded late yesterday afternoon that the following specific failures by the NI Prison Service contributed to the death of Mr Stewart;

1. The lack of CCTV on the prison landing at Lagan House.
2. Insufficient prison officer staffing levels.
3. A lack of clarity among staff regarding what type of checks were required throughout the night shift.
4. Prison staff checks on prisoners were not being carried out consistently on the night of Mr Stewart’s death.
5. A “peg” logging system was used for checks which was not proven evidence that a check had actually been conducted.
6. Staff worked 24 hour shifts.
7. The policy for dealing with vulnerable prisoner checks at the time (SPARS) resulted in other prison inmates who were not being treated as vulnerable being overlooked.

Mr Stewart’s sister Joanne Griffiths said today;

“We hope that the findings of this inquest will lead to much needed change.  There were clearly missed opportunities by prison staff which may have saved Jonathon.   As the jury found, there were systemic and specific failings by the Northern Ireland Prison Service which, had they been avoided, may have saved his life.  While on remand for an offence he disputed he was moved to Lagan House just a few days before his death.  Lagan House, a 2 storey building with 6 landings built in a square, had CCTV only on one landing, landing 3.  There was no CCTV on landing 6 where Jonathon was housed.  No valid explanation has been provided for the absence of CCTV on the other landings in Lagan House.

There were also failures in the initial police investigation into his death. In terms of the police investigation the missing blades in Jonathon’s cell caused us enormous distress and uncertainty for over 6 years.  We do not want another family to go through this.  The lack of information and the delays and errors in communicating the limited information which was available to us were unacceptable. 

Our experience has led us to the conclusion that every death in custody in Northern Ireland should be treated as a major investigation incident until it is no longer deemed to be one.  The current criminal investigation system for deaths in custody at Maghaberry involves local police but not Major Investigation Teams.  MIT teams could treat every death in custody with proper evidential protocols – the gathering of forensic and physical evidence, the immediate taking of witness statements, preservation of the scene and the uplifting of all available evidence including CCTV and the checking of cell and landing alarm information.  This would ensure that essential evidence, such as the missing blades in Jonathon’s case, would be found.  It is not enough that the Prisoner Ombudsman is granted access.  Her investigation should not replace a full and proper police investigation.  A death in custody should be treated no differently from a death in the community. 

In Northern Ireland there have been 51 deaths in custody across 3 prison sites recorded since February 2009.   It is my intention to initiate a campaign to try to bring a change in Northern Ireland so that any death in custody is investigated by a police Major Investigation Team.  I want to dedicate that campaign to Jonathon so he did not die in vain.  We do not want another family to have to deal with doubt and distress we dealt with over the past 6 years.”

Patricia Coyle, solicitor for the family said today;

“My clients welcome the jury verdict in respect of the circumstances of Jonathon’s death.  Jonathon had no history of mental health problems either before or at the time of his death.  My clients do not believe that he intended to take his own life.  The jury verdict includes significant findings of inadequacies in the prison system in relation to staffing, consistency of and clarity regarding the nature of the different types of requisite checks on prisoners and the critical absence of CCTV in Lagan House.  They hope that lessons can be learned from Jonathon’s death by both the prison and police authorities so that these mistakes are never repeated.”

 

Contact

Patricia Coyle

Harte Coyle Collins

Solicitors & Advocates

9-15 Queen Street

Belfast

BT1 6EA

02890-278227