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00:0820 years ago the touch paper was lit on a promised revolution in how we care for those
00:13with mental illness in Ireland. A report for government has recommended the closure of all
00:19mental hospitals and the reinvestment of all of the funds released from the move
00:23into developing psychiatric health services. The days of bleak asylums it seemed were
00:29over institutions were to close it was to be a new era of community care. A vision
00:37for change was a good policy in 2006 it is a good policy in 2026 it simply hasn't
00:43been implemented in full. Many old wards were shut with a plan to open specialist
00:49replacement services. It should have meant opening up lots of facilities health care
00:55facilities could have been assisted living nurses care didn't happen. But what did
01:01happen was even more disturbing. Without acute beds mentally ill patients are
01:07being sent to prison. They shouldn't be here they should be in a hospital that's
01:11where they should be. In many cases there is nowhere else to go but through the
01:15criminal courts. We are warehousing people with very serious mental health problems
01:19in the prison population. Today many mentally ill people are being treated in the only place
01:26that will accept them. They're not scumbags they're someone's brother, someone's son,
01:32someone's father. Here in chronically overcrowded facilities and cut off from family and friends
01:40sick people are confronted by isolation, injury and even death.
01:46It felt like we were in court for mental health. It didn't feel like we were in court for a
01:52murder.
02:01There's nobody similar to Greg. He's sort of unique.
02:12Peter O'Toole from Wicklow turns 90 this year. His son Greg is 45. Greg has an intellectual disability
02:22with psychiatric symptoms. In February 2024 Greg was charged with minor offences and held on
02:31remand in Cloverhill prison. He has not been sentenced or even faced trial.
02:37Well he's been kept in Cloverhill because the HSC is nowhere suitable for him. He's been there now for
02:45a year and they still haven't found a place.
02:54Whether it's in prison or court, Peter will support his son, usually with a pit stop at the local shop.
03:04Tobacco or chocolate, he appreciates that all right.
03:10Can't abandon him, no.
03:13Because he was a good lad at one time. Hopefully he will be again.
03:20The HSC has become increasingly reliant on private residential centres, spending 95 million
03:27euro last year on mental health providers here. But none could accommodate Greg's needs.
03:33In court, he was accused of damaging HSC property and a local church floor and stealing some milk. But all
03:41sides agree that that is not why he is in prison. Of course it's not the right place for him.
03:49There surely must be somewhere else or something that can be done.
03:54Medication wise and accommodation wise. I suppose the HSC is an awful lot of cases,
03:59but I don't know if there are many cases like Greg's. It is different. It is a bit
04:05frustrating that something hasn't happened so far. Every fortnight Greg is transported from Cloverhill
04:13Prison in Dublin West to Bray District Court in County Wicklow. He has not been sentenced. He is led
04:20there in handcuffs simply because he is sick. Expressing his frustration, the judge hearing the case
04:27told all parties that Greg should not be in prison. But that is where society has put him.
04:35We keep hoping for something to happen. And hopefully it will. Soon.
04:44There was a time when Ireland had no shortage of beds, housed in vast psychiatric institutions,
04:51prominent in towns across the country. Other countries embraced asylums,
04:56just like Ireland did. But no country embraced them as much as we did. So by the time the 1950s,
05:031960s came along, Ireland had over 20,000 people in public mental hospitals, as they were called.
05:12That per head of population is more than any country in the world at that time, or before, or since.
05:2020 years ago, the government of the day announced it was overhauling the system entirely.
05:26It launched a vision for change. Today's report of the expert group on mental health policy says
05:33developing services in the community is the priority, and it recommends the closure of all
05:37remaining 15 mental hospitals. This has guided our mental health policy ever since.
05:44A vision for change was a good policy in 2006. It is a good policy in 2026. There's absolutely nothing
05:51wrong with this. But the very same proposals to switch to community-based care had been made by
05:57governments for decades. In June 2020, the policy was restated. Again.
06:03Today Minister Jim Daly and I will publish Sharing the Vision. You may have heard of Vision for Change,
06:09a policy launched in 2006. And today we publish a refreshed version of this policy.
06:15The HSE and the Department of Health told RTE Investigates the goal of sharing the vision is to ensure those
06:23encountering forensic mental health services can access comprehensive tiered mental health support.
06:29The department said last year an implementation plan highlighted good progress overall.
06:41To investigate the situation on the ground, we travelled to court hearings and inquests across the country.
06:47We spoke to the families of inmates and those working at the coalface. We poured over hundreds of first-hand
06:54accounts,
06:55investigation reports and post-mortems. And we visited the prison landings that are struggling to cope.
07:01We found a country choosing to lock away some of its most acutely sick citizens.
07:09What we see is the criminal justice system starting to see more and more of those people who would
07:14traditionally have gone into mental health care settings, end up in prison and having to cope with that.
07:21The facts are stark. In late 2025, psychiatrists based in prisons were treating 341 inmates,
07:29a 40% increase in two years. The number of prisoners waiting to see a psychologist
07:35rose by 80% in just three years. And the impact of hospital closures is undeniable.
07:42Prisoners are now equivalent to 14% of all people on psychiatric wards in the country.
07:49What other countries did was to develop diversion and Ireland hasn't done that. And as a result,
07:55we are warehousing people with very serious mental health problems in the prison population.
07:59In Greg O'Toole's case, a solicitor for the HSE told Bray District Court that Greg was in custody
08:06because there was nowhere for him to go. But alarm bells have already sounded, warning us just how
08:13unsuitable prisons are for those in the throes of a mental health crisis.
08:18So what happens is, prisons become the last resort, the place that scoops up everybody who can't be
08:25dealt with anywhere else, where there's no services anywhere else. It's also the worst place to put people
08:31with mental health challenges.
08:35Yeah, he was a happy lad. He had loads of friends.
08:4029-year-old father of two, Andrew Gurns, was a compressor engineer by trade, but a footballer at heart.
08:48He was a good father. He loved his two children. He was a hard worker when he was working.
08:58He was a rogue as a child.
09:01He was an unbelievable soccer player. He got trials for Liverpool.
09:06He was a brown-eyed boy. Yeah, he was the favourite one.
09:13Andrew's life changed drastically following a relatively minor road crash that left him with severe back pain.
09:22He had a car accident and he went to a doctor who gave him painkillers. But very quickly,
09:31he got addicted to him. Then he started to buy tablets on the streets. Then he got into the heroin.
09:46It's just, that's when we started reading, honestly. Just spoiled it out of control.
09:51He spent short spells in Cork prison, including for assault. And in 2020, he was sentenced to two months
09:59for breaching a barring order. Garthie called to his mother's house to take him into custody.
10:05He put all his two hands on the handcuffs and they said, no, you're running through.
10:10And they set him into the back of the car and off he went. That was the last we'd seen
10:13him.
10:13Andrew's mental issues trace back to the accident, but his addiction had made outpatient psychiatric
10:19care difficult. He had expressed hope prison would help him get clean, but it ultimately showed
10:25how ill-equipped it was to treat him.
10:27The jury at an inquest into the death of a 29-year-old man who took his life six days
10:32after
10:32he was committed to Cork prison has recommended that an independent review of all medical care
10:38at the prison be carried out. The family believe his life could have been saved with different care
10:44and intervention. The inquest heard a glitch in a faulty prison IT system, confused his medical records
10:51and previous suicide risks. As a precaution for Covid, Andrew Gurns was placed in a cell on his own.
11:07It had a tubular bunk bed and a plug-in kettle with a cable. Laces were not removed from his
11:14shoes.
11:15Clearly, where a prisoner is ending their life, there is a lot of scrutiny for the state in relation
11:23to that. And under Article 2 of the European Convention on Human Rights, there is a right to life
11:28and there is an operational obligation on the state to protect their right to life, including
11:32respected prisoners who were very vulnerable. During his six days in prison, medical notes recorded
11:39him being delusional, hallucinating and suffering brief psychosis associated with withdrawal.
11:45An appointment was made for him to see a psychiatrist. He phoned his mother, Aideen,
11:51and the conversation was recorded. To Aideen, it was obvious that Andrew was hallucinating.
11:57Are you still in isolation? Yeah, you're was only seeing my face today.
12:04Who? That nurse one, it hemorrhaged there. It hemorrhaged?
12:09Just all this started cracking and loose skin coming back out again like.
12:14I think it's five minutes or six minutes phone call you get, which I thought the minutes would never
12:20be up because I knew I needed to ring to get help for Andrew because I knew he wasn't
12:27well at all at all at this stage. I goes, I was assaulted. She goes, Andrew,
12:33you're in isolation since you came in. And who, and how did you get assaulted so like?
12:39Because I got someone to switch over to like the fucking, the fucking signs on my door and put them
12:44on the man next door. Oh, right. And then I just caught the officer. Like, some officers,
12:49I called him off guard now. Do you know what I mean? And said, officer, leave us out there, please.
12:54And left us out in the landing. And left you out? Yeah. And where did you go when he left
12:59you out?
13:00Down towards Blackpool. So I didn't actually know what was going on. And I'm like, was he dreaming?
13:07But then when I realised what was happening, I rang him then straight away.
13:13Medical notes said Aideen was reassured that staff were aware of his state.
13:17He was safe. And they were keeping a close eye on him.
13:22And I thought, that's all right. He's been looked after us. That was grand.
13:28Despite his delusional state, Andrew was never classed a suicide risk. So the relevant prison
13:34safety and observation protocols did not kick in. About four hours later, Aideen got a call from Cork
13:42prison. Her son was in intensive care. I actually really, really thought he was
13:49coming home and he was going to get better. They had him in a reduced coma. So I said,
13:54as soon as they wake him up from this, he's going to come home. I did not know.
13:59He was in hospital for 10 days after five days. We had a meeting. And then he decided to
14:05run off the machine. He said, no. He lasted another five days. And died on the 7th at half
14:13the morning. Andrew Gerns' death here in Cork was one of an increasing number of tragic events
14:26in Irish prisons. We gathered all available public records for everybody who died in custody since
14:332012 and a clear pattern emerged. In 40% of fatalities, mental illness played a significant
14:41role in either their crimes or their deaths. And among those cases, the most common feature
14:48was young men who died by suicide. The quality of prison conditions can undermine people's mental
14:57well-being. It creates a sense of despair and distress as a place where people are more likely to
15:03commit suicide. So they know about that risk. And therefore, they should have effective
15:07policies in place to address it. Unfortunately, Andrew Gerns' death was not the first time
15:14the dysfunction between prison conditions and effective healthcare was exposed.
15:21Sean was very quiet. Never much agonist or anything like that.
15:27In early 2017, 31-year-old Sean Hayes Barrett was a psychiatric patient at University Hospital
15:35Limerick. Hours after being signed out, he was arrested and committed to Limerick Prison holding
15:41a prescription, his medication and an appointment letter to see his consultant. His late father,
15:46Shani, remembered his son. And he was good. He was a baby. He was good. He was brought to prison,
15:59but his hospital records, and more critically, his medicine, was confiscated on his committal.
16:05He listed his next of kin as a friend who we call Jane. Her words are voiced here by an
16:11actor.
16:14Sean, in my head, was somebody that needed people to help him and to support him.
16:20He didn't know what was going on, to be honest with you.
16:23With his tablets for psychosis confiscated, he went two days without medication,
16:29four times he phoned Jane. And he was like,
16:32I can't handle this. I'm hearing voices and everything now in my head. I need my tablets.
16:39So I rang the hospital where he was discharged. And I said, look, this is after happening and we
16:45need Sean's medication administered to him. I said, is there anything that you can do?
16:51Duty of care is the same for people who are in hospitals or residential care. You know,
16:56that is the exact same duty. It's no different. When you take away someone's ability to feed,
17:01clothe and house themselves, then you have to do those things,
17:04or you're looking at a loss of life that's on your hands.
17:08I didn't know what to do. You know, you could tell he was deteriorating because he spoke with almost
17:16panic in his voice, panic and fear.
17:22In fairness to prison staff and the clinical staff in prisons, they do work very hard to do their
17:28best. But at the end of the day, prison is prison. It is not hospital and it will never meet
17:34the needs
17:35of people with mental illness.
17:37Jane had just completed a dawn walk for darkness into light when she got a call from Limerick Prison.
17:45Her friend had taken his own life.
18:01The inquest was held two years later.
18:05A number of prison officers told his inquest they did not know he was on special observation
18:10and therefore did not check him every 15 minutes as required. Coroner John McNamara said there seemed
18:17to have been a systems failure around the prisoner's care.
18:20I was told this was a landmark case. That it was going to instigate a whole overhaul of the prison
18:27system.
18:28Far from it.
18:30He needed somebody there on the inside that could get to him.
18:35Because I couldn't get to him quick enough to help.
18:42Despite these failures, more people with mental illness are ending up in prison.
18:47We have established that in 2024, one in every 20 new inmates required psychiatric care.
18:54And last year, hundreds of prisoners deemed to need psychological treatment were released before
19:00they could even get it.
19:05Which is a disgrace. Like are they not learning?
19:08Just give them the basic medical care that they need.
19:12Are they right for prisons? Are these prisoners right for being in prison?
19:15Or do they have to go up to a psychiatric ward?
19:18Is the hospital a better place for them? You know? I don't know.
19:24But the reality is, hospitals will not accept some patients, like Greg O'Toole,
19:30who instead has been locked up here at Clover Hills D2 Medical Wing for the past nine months.
19:36His sister Katrina, an experienced psychologist, feels she has run out of options.
19:42It's really, it can be exhausting. I won't lie. It's, and I don't know how some families do it, you
19:50know.
19:51Nobody wants to tell your story publicly. I think, you know, none of us want to do that.
19:55Certainly myself and Dad, I don't want to be, you know, we don't want to be in that position.
20:01But we just felt we had no choice.
20:06I don't think anyone who comes before a court and requires mental health care should be sent to prison to
20:13get that care.
20:14They should be, you know, facilitated to access the care in the community or in a dedicated medical facility if
20:22that's necessary.
20:29What are you feeling about today?
20:31Oh, a bit worrying. I don't know what's going to happen.
20:36Hopefully they'll be released if they have someplace.
20:39Fingers crossed.
20:41We have established that the HSE spent an average of 1.2 million euro on nine psychiatric patients sent to
20:49the UK for residential care in 2024.
20:52At today's court hearing in Bray, the HSE proposed sending Greg abroad too.
20:59We see Greg, the confusion, the worry, and I just see every time the anguish on Dad's face, you know.
21:08I just feel, it's, you know, it's just shameful. It's not acceptable.
21:15I don't like any talk of the UK at all, because it wouldn't be good for him.
21:22He loves home, you know, and that's all he needs at the moment.
21:39Joseph Fay is in his 50s, but has struggled with manic depression and schizophrenia since the early 1990s.
21:46His symptoms, triggered by abuse he suffered by strangers and the killing of his older brother in a random attack,
21:53Joseph spent time in a number of the old psychiatric institutions, particularly at St. Loman's in West Dublin.
22:00There was a bed, always a bed. There was always a bed for him in the old system.
22:05There was lots of, there was a difference. He was in Brendan's, Loman's...
22:10Dundrum.
22:10Dundrum. But there was three different places.
22:13And what we could do under the old system is we could always visit him.
22:18So we had a relationship with him. We was there, we were helping him.
22:22They were dreary looking. That was it. But it was help. It was help because it wasn't a prison.
22:29After those hospitals closed, the only viable option was to involve the GardaÃ.
22:35Joseph responded by running away.
22:38And then you're worrying, where is he? All night, like, because he's wandering around and he's sick.
22:44When Joseph finally showed up, the Fays could not find a healthcare setting to help.
22:50You're on your own. There's nobody you can go to. Literally nobody.
22:57At home, Joseph's behaviour could be erratic, sometimes violent.
23:03I'd done the dinner and we were in the kitchen. And he said, I was poisoning him. And she said,
23:09you're not... And then he got you up against the wall, didn't he? And I was afraid to move because
23:14he had his fist up. I was afraid he was going to smash her head into the wall.
23:17I was frozen and that was the most frightened I've ever been of him. And then as part of that,
23:24one night he wanted to set the house on fire. It was all in it.
23:29His mother took out a barring order so Gardaà could intervene if necessary. Any breach
23:35would mean arrest and sending Joseph to prison.
23:39I just felt... I felt terrible because I got the barring order, didn't I?
23:47And I don't think they should be in prison, they should be in hospital.
23:51It's about choices, about what we're going to do. Are we going to build, you know, cement boxes
23:56with security perimeters? Is that our best idea and our best investment of a huge amount of money
24:01to deal with a mental health problem?
24:04Joseph Fay made no secret of his fear of prison. On release, he went missing again.
24:12I've gone past thinking he's dead when he goes missing now. I'm watching my mam unravel.
24:18I'm like, relax, relax. We found him the last time, we'll find him again.
24:21He's thrown up.
24:29This is Jordan growing up and the rest of the family.
24:33Their names are there after them and even some of the grandchildren now are starting to do it.
24:38There he is all the way up to the top, up to six foot four.
24:42Smith shot up. Where was he? He was here in 2015.
24:47Yeah.
24:49Jumped. Jumped again.
24:51Yeah. Well, that was the last, unfortunately.
24:55It's just another reminder that he existed.
25:02Jordan Kavanagh was treated for anxiety and depression as a teenager.
25:07The second time he attempted suicide, he was rescued by his grandfather, Martin, and other family members.
25:23Can't get through it anymore.
25:25Yeah.
25:25It's the street down there.
25:27Well, it's, this is a place I've never visited since.
25:38So, I'm sorry lads, I have to get out of here.
25:48After recovering from multiple injuries, Jordan was discharged from hospital and psychiatric care.
25:55He stayed with his grandparents and took well to an apprenticeship.
26:00Yes, he was in hospital for about nine days. He was in ICU for quite a long time.
26:05I didn't think he'd come out of it.
26:08So, eventually he did.
26:10And he came around as normal with no injuries of any description.
26:14And came back to normal.
26:17Whatever is normal.
26:21He had a mental problem.
26:26But in general, he was okay.
26:29But there's times when he required help.
26:32And he got help most of the time.
26:35But, unfortunately, when he really needed it, he didn't get it.
26:40A year later, he was before court for his involvement in a serious pub brawl in Kilkenny.
26:46Jordan Kavanagh was sentenced to two years at Midlands Prison, Portlaoise.
26:51His first experience of serving time.
26:55A psychological report for court said he was friendly, polite, but psychologically vulnerable.
27:02It concluded the risk of him committing another violent crime was low.
27:07He wasn't a saint.
27:12He'd done his fair share of wrong things as a teenager.
27:15But he'd never done anything like that before.
27:18And I'm sure he would never have done it again.
27:23These things happen, unfortunately.
27:25I mean, people do commit horrendous crimes.
27:28And they have to be put somewhere.
27:31And the people that look after them have a very serious job to do.
27:36But other than that, I wouldn't know much about what happens in prisons until Jordan went in there.
27:42If you read the files, you'll see that he had already attempted suicide some short time before that.
27:49And had done so a few other times.
27:52He was seen by the prison's forensic psychiatric team on nine occasions.
27:57They prescribed a medication for ongoing anxiety and noted a history of deliberate self-harm.
28:04Jordan was described as an exemplary prisoner.
28:08Despite regular visits, his family and fellow inmates grew concerned about him.
28:13My wife asked for him to be looked at one day in particular.
28:17that he looked very anxious, very annoyed.
28:22And she rang in to know he'd be looked at.
28:26But we never knew whether he ever was or not.
28:29Seven months into a two-year sentence, in cell 35, on landing 3B,
28:36Jordan Kavanagh took his own life, making use of a broken perspex window.
28:44Three years earlier, windows at the prison had been identified as defective and in need of replacement.
28:51A UK expert compiled an independent report, noting that mental health facilities must eliminate
28:58any opportunity for patients to self-harm.
29:01But a prison is not a mental health facility, and Jordan's cell provided easy access to all he required.
29:10Jordan's grandfather visited the cell afterwards.
29:14You have to realise that this is the last place he was alive.
29:23So, you can understand what it meant to us.
29:29You know,
29:34He was my grandson, not my son, but he felt like a son to me.
29:45I'm sorry, no, I'm sorry.
29:55Nine days later, at the same Midlands prison, another young man, also from Kilkenny, used another defective window to take
30:04his own life.
30:11In a statement, the IPS said that following death inquiries, it takes all recommendations extremely seriously, and ligature reduction works
30:21have been undertaken.
30:22Our prisons are currently packed beyond capacity.
30:26It is a tense environment for prisoners, and an increasingly dangerous one for prison officers.
30:32The Prison Officers Association says attacks by inmates on prison officers increased by 32% last year, when 145 officers
30:41were injured.
30:43The reality is that prisons are dangerous places at the best of times, but these are not the best of
30:50times.
30:51Currently, we're seeing a severe overcrowding crisis in our prisons.
30:57They're well over 100% capacity. In some prisons, it's 150%.
31:02So, you can imagine the tensions that are in prisons at the moment with those kind of conditions.
31:09In many of these cells, adult men are confined to that space for 22 or 23 hours a day.
31:17So, they're eating and sleeping and drinking and defecating in these spaces together.
31:27The Chief Inspector of Prisons told this to the Council of Europe's Committee on the Prevention of Torture at a
31:33CPT conference in Dublin in October.
31:36Inhuman and degrading.
31:39Unworthy of Ireland in 2025.
31:44The CPT provides independent oversight of prison conditions in Ireland.
31:50It reports its findings directly to government.
31:54It's really disappointing.
31:56Little regard seems to have been paid to a number of long-standing recommendations in relation to prisons.
32:07The committee described conditions it found in a two-man cell on Clover Hill's D1 wing.
32:14Four men were being accommodated and there was a bunk bed, a single bed, and a man who was very
32:24clearly mentally unwell was required to sleep on a mattress on the floor.
32:30Not an environment that's healthy for any person, let alone a man who was clearly mentally unwell.
32:45The Irish Prison Service provides psychological care in prisons, but not psychiatric care.
32:51That is actually provided by the HSE.
32:54At Clover Hill, the HSE's National Forensic Mental Health Service runs a dedicated medical wing, D2, where Greg O'Toole is
33:03held.
33:03The psychiatric team at D2 is headed up by Professor Conor O'Neill.
33:10Yeah, it's a challenge.
33:11Prisons are not healthcare delivery environments.
33:16The role of a prison to be, or pretend to be, if you like, a hospital or something like it.
33:22But, you know, there are a number of people that just should not be here.
33:28Oh, he was a man who struggled with his mental health, but he was a really good dad.
33:39Courtney Rosny from Furban, County Offaly, named her newborn daughter Ivana after her own late father, Ivan Rosny, who experienced
33:48mental illness from an early age.
33:52From the age of 21, he was in Portlaoise Hospital for an injection to help him stabilise his moods.
34:02When he was on his medication, what was he like?
34:06He was very good. He was what you would expect a father to be. He was really good to us.
34:12We never were short of anything. We were never short of love, and that's for sure.
34:17In late September 2020, Ivan Rosny had missed his daily medication.
34:23Gardaà were called to an argument outside his father's house.
34:27For reasons that have never been explained to his family, Ivan ended up in Cloverhill Prison, instead of Portlaoise Hospital,
34:34where he had been an inpatient many times.
34:38I'm sure he was very, very confused when he was in the prison, and wondering why he was there.
34:45And what did he do wrong for him to be there?
34:49Held in custody over the weekend, where his family aren't sure about his access to medication,
34:54he was to appear before Mullingar District Court on Monday morning by video link.
34:59His family have not been told the full circumstances of what happened next.
35:04They do know that Ivan, aged 36, died after he was taken from his cell, while being restrained by several
35:11prison officers.
35:13We were told at the start that there was five to six prison officers restraining Dad.
35:18We haven't been told what exactly went on, or why he wasn't brought to Portlaoise in the first place.
35:27When his body was returned, the family noticed extensive bruising, but do not know what caused it.
35:34No inquest has been held.
35:37Gardaà told the coroner that a file would be prepared for the Director of Public Prosecutions, but no charges were
35:43brought.
35:44CCTV footage was not released.
35:47Courtney has been fighting ever since, to find out how her father died in custody.
35:54It's a very big thing to be fighting at 23 years of age.
35:58I mean, my family are behind me, but it's just me.
36:01So, it's a young woman fighting against all these big prison services, the HSC, the GardaÃ.
36:10So, they'll kind of just look at me as if you're wasting your time.
36:16As a TD, Jim O'Callaghan had taken up the family's case and committed to find reasons for the delay
36:22with the inquest.
36:24We have confirmed that as Minister for Justice, a report into Ivan Rosny's death had been on his desk since
36:30October 2024.
36:33It is one of only two that have remained unpublished for more than a year.
36:37We've suffered long enough, it's been five years, it's been long enough, not to know what's happened.
36:44If I could talk to the Justice Minister myself, I would ask him a simple question.
36:51If this was your family member, this was your dad, what would you do?
36:57We sought its release under the Freedom of Information Act.
37:01The Department refused, as considerations on the possibility of the redaction of certain details are underway, and legal advice is
37:09awaited.
37:10There have been no redactions evident in more than 160 other death in custody reports published in the last decade.
37:19I'm not asking them difficult questions, or questions that they have no answers to.
37:26They have the answers to the questions I have, but they're just refusing to give me those answers.
37:32Minister O'Callaghan said he had submitted a parliamentary question on the family's behalf in September 2024, regarding the inquest
37:41delay.
37:42A statement said the Department was consulting with the Attorney-General on the content of the death in custody report,
37:49and subject to this, it was his intention to publish it shortly.
37:53In recent weeks, the Rosny family was told an inquest was to be scheduled in March this year.
38:00Meanwhile, other reports have been published, revealing that Ivan Rosny was not the last acute psychiatric case to die in
38:08Cloverhill.
38:09In August 2022, this man, referred to by the Inspector of Prisons as Prisoner O, was refused permission to board
38:17a flight at Dublin Airport.
38:19He appeared psychotic, chanting, and kept talking to a wall when detained by GardaÃ.
38:25He was arrested.
38:27When he initially appeared before the court, he was bailed against zero cash, but because of his mental health condition,
38:37he was in no condition to take up that offer, and he ended up in prison.
38:44In Cloverhill's holding cell, he did not follow instructions.
38:47He was escorted to the D2 medical wing to a special cell for problem prisoners.
38:53A court said charges would be dropped when a bed at St. Vincent's Hospital Fairview opened up, but a day
39:00before that happened, and after less than a week in prison, he was found dead.
39:05An inquest has yet to determine how.
39:09This was a man who was mentally unwell, who had been placed in a closed supervision cell, who was noted
39:20by prison staff not to be eating or drinking in the 48 hours prior to his death, yet absolutely no
39:34action was taken.
39:38The man's family have given us permission to name him as John Bull Amaragban, a Nigerian-born Spanish citizen and
39:45a much-loved father of four.
39:47They say he was diabetic.
39:49He had been visiting family in Cork and was trying to fly back to Spain to get treatment for a
39:55relapsed psychiatric illness when he was arrested.
39:58Instead, he was sent to prison.
40:00His family said they had been fighting for three years to establish the full circumstances of his death.
40:07In the resulting inspector of prison's report, a treating psychiatrist lamented this as an example that despite a vision for
40:16change, prisoners needing community care were still not receiving the mental health treatment they require.
40:23The vision for change was a lovely idea, but unfortunately, in practice, we have a situation where the community mental
40:31health teams simply do not have the staff.
40:34That's it.
40:38I'm just out of Cloverhill District Court, where today there were 42 people facing charges.
40:44The overwhelming majority are being held here inside Cloverhill Prison.
40:49We now know that of those 42, seven are currently in the care of the prison psychiatric team.
40:55Some are just waiting for beds to open up at appropriate treatment centres.
41:00But for now, they have nowhere else to go.
41:09Joseph Fay's family in Dublin had no idea where he was until they got a phone call from Pentonville Prison
41:16outside London.
41:19On one hand, it just means so much to know he's alive and he's well.
41:26And then it's the slap in the face again of he's in another prison.
41:32He's still not safe because he's so vulnerable.
41:35He's a sick, schizophrenic Irish person in a prison in England who knows nobody.
41:42And he didn't get a life.
41:47Just didn't get a life.
41:48There was no help.
41:49There is no help.
41:53After almost 18 months in Cloverhill Prison, Greg was released to allow the HSE send him to the UK for
42:00care at a residential facility.
42:03This is not how Greg's life should have turned out.
42:10And it's a struggle to see him in there and to see why he's up against.
42:22Sending Greg abroad was never what the family wanted.
42:26But while in the UK, he will be treated as a patient, not a prisoner.
42:46In this vast complex in West Dublin, there are two prisons, Wheatfield and Cloverhill.
42:53Wheatfield holds over 400 sentence prisoners, mostly from the Leinster region.
42:59Cloverhill is the country's only remand prison.
43:02Here, on any given day, more than 500 men are typically held, waiting for a day in court to plead
43:09or face trial.
43:12Remand prisoners should be treated as someone who's not been convicted of anything.
43:16And so no one should be detained pre-trial unless there's an absolute need to do so.
43:20Potentially because they present a threat to witnesses or to others.
43:25But if you are being held on remand, you should be treated as if you're innocent because that's what you
43:31are.
43:31And we still have a principle of innocent until proven guilty.
43:33In the last 10 years, the overall number of prisoners has gone up by 50%.
43:39But the number of prisoners on remand has more than doubled.
43:44Cloverhill, like all prisons, is operating well beyond capacity.
43:49Built to house 460 prisoners, recently up to 550 men have been kept there.
43:56One in every five inmates sleeps on a mattress rolled out between beds and toilets.
44:02Conditions for remand prisoners are amongst the worst that you will find in the country.
44:09But if we're talking about people who perhaps have had pre-existing mental health issues or substance use issues,
44:17to place them in that situation directly from the community or from court, I think is certainly having an impact.
44:29This is Cloverhill, the country's remand prison, where people begin their prison journey.
44:34But each year, it also sees so many acutely mentally ill people that it compares with some of the busiest
44:41psychiatric hospitals in the country.
44:44Medical treatment centres on the D2 landing, which is designed for 27 men.
44:50Here, the number of seriously mentally ill inmates is rising even faster than the overall prison numbers.
44:58When people arrive at the prison, they go through a screening process.
45:01So, they're asked questions about their mental health, about whether they're on certain kinds of medication,
45:07if they're thinking about harming themselves, things like that.
45:10In four years, the number of actively psychotic prisoners at Cloverhill has tripled.
45:16Last year, more than 10% of the prison's population were in the midst of psychosis.
45:22Conditions like schizophrenia and related conditions like schizoaffective disorder, bipolar disorder.
45:27And these are some of the worst mental health conditions you can have.
45:31Where people can hear or see things that aren't real.
45:35It's usually voices saying abusive or threatening things.
45:41Prisons are not approved centres in terms of the mental health legislation.
45:45So, if you have people who have open, active, florid psychosis and who decline treatment that could be of real
45:53assistance to them,
45:55then that treatment can simply not be given in prison.
45:59The most recent report of the Cloverhill Visiting Committee praised the efforts of the psychiatric team and prison staff,
46:06but highlighted an absence of appropriate community health facilities and long waiting lists for forensic beds at the Central Mental
46:14Hospital.
46:16The reality is that the minor charges facing most of these men do not warrant care at the Central Mental
46:22Hospital.
46:23Besides, there is no room at the CMH.
46:26As the second programme in this series will examine in detail,
46:29more than 30 people in prison are currently waiting for a bed there.
46:36Vision for Change envisaged four regional secure units.
46:42So, what these would be would be a midway unit where people with severe mental illness who are behaviourally disturbed
46:49could be safely managed rather than them ending up in prison or the Central Mental Hospital.
46:55But 20 years have passed since that policy was launched.
47:00It's really important to have those commitments, but unless you have the follow-through,
47:05unless you have the commitment to investment, the commitment to delivery,
47:10then they're not always worth the paper they're written on.
47:13And we've seen that in the forensic mental health setting.
47:17Sheer pressure and numbers has left the Irish Prison Service putting more people into shared cells than it is safe
47:23to do so.
47:25As was the case when three men were placed in one cell on Clover Hill's non-medical D1 landing in
47:31October 2024.
47:33The violent attack in Clover Hill Prison, which led to the death of an inmate,
47:38began in the early hours of this morning.
47:40The two surviving inmates who were in the cell at the time of the attack
47:43have been removed to different parts of the prison.
47:46In my view, people who should never have been placed together were placed together.
47:54with a fatal outcome for one of those prisoners.
47:58So when I wrote to the minister, my conclusion was that the accommodation in D-Wing in Clover Hill
48:04of multiple prisoners who hadn't been risk assessed in one cell was life-threatening.
48:11The IPS told RTE Investigates the risk profile of each prisoner is continuously assessed,
48:17but that the accommodation of people with major mental illness is challenging.
48:22It said prisons are not mental health facilities.
48:26It wasn't the first violent and fatal incident involving a prisoner with mental illness at Clover Hill.
48:35Mark was actually comfortable in prison, which is a pretty sad thing to say.
48:43Mark Lawler from Ballymun suffered childhood trauma twice.
48:47First, he was sexually abused by an acquaintance,
48:50and then he saw one of his friends die in a freak accident.
48:56Mark was really never the same after that.
48:59The heartbreak over being abused.
49:02Mark's life just started spiraling out of control.
49:05He started getting into a bit of trouble.
49:07Fights, this and that.
49:10His family struggled to find help from psychiatric services available at the time,
49:16including local hospitals.
49:18All I remember is the heartbreak from Amanda.
49:27Because I think they felt they were getting nowhere trying to help them.
49:34And now mother and father wants to see their son with mental health problems at such a young age.
49:44Mark moved into the inner city and became homeless.
49:47On visits home, his psychotic episodes caused chaos for the family.
49:51Following a string of minor convictions,
49:54he received a four-year sentence for harassing the Garda,
49:57who was investigating allegations that Mark was sexually abused as a youngster.
50:03At that stage, Mark wasn't taking his medication,
50:05and he ended up in a fairly bad place.
50:08He was hearing a lot of voices in his head at that time.
50:11He stabilised with the assistance of psychiatric services at Mountjoy Prison.
50:16In some ways, it was better for him than being homeless.
50:21Because he always used to say,
50:23I'm OK in here.
50:25I'm fine in here.
50:26I know the lads in here.
50:28And I think me ma used to be a bit of peace of mind
50:30because he was getting his medication every day.
50:33In previous spells, Mark was settled on Mountjoy's medical wing,
50:37but minor offences in 2019 saw him remanded to Cloverhill.
50:42Instead of going into medical care, however,
50:45he was put in with the general prison population.
50:48He was still on heavy medication.
50:53He was classed as being OK and was put up to a landing into a cell
50:59with another chap.
51:01And then, three nights later, another person was put into the cell.
51:07Michael Connolly and Mark Lawler were sharing a cell.
51:10Both men had mental health issues and were alone
51:13when Connolly borrowed a kettle from the cell next door
51:16and scalded Mark Lawler before strangling him.
51:20Lawler was a 38-year-old man from Drumcondra in Dublin.
51:23The judge today described him as a good and decent person,
51:27the apple of his mother's eye.
51:30It's even a ticking time bomb to put somebody
51:32that's schizophrenia and bipolar in a cell with another,
51:39what do you think, I don't want to say normal person,
51:41a person in their right frame of mind.
51:44Because one thing can just trigger off.
51:47At the trial, the court heard that Michael Connolly's sister
51:50had warned the prison of her brother's deterioration.
51:54She had contacted the Gardaà by phone and email about her concerns
51:58and tried to have her brother committed to an institution before the killing.
52:04Michael Connolly's sister was told no therapeutic services were available.
52:11We went to court.
52:13It felt like we were in court for mental health.
52:17Because that's all we heard.
52:20Every five minutes.
52:22Mental health act, mental health act.
52:25It's all we heard.
52:26It's nothing.
52:27Nothing really about a murder.
52:32There's something wrong there, if you ask me.
52:38For 20 years, a novel legal mechanism called therapeutic bail
52:43helped transfer hundreds of mentally ill prisoners to hospital.
52:47But we can reveal that just before Christmas,
52:50a constitutional challenge in the High Court
52:52led to the suspension of the practice.
52:55Greater numbers of psychiatric patients
52:58will now remain behind bars.
53:01Justice Minister Jim O'Callaghan said
53:04therapeutic bail was a matter for the courts
53:06and the Irish Prison Service must accept into custody
53:10all people committed to prison by the courts.
53:13And a pilot project in Limerick
53:15that diverts people in mental health crises
53:18away from the courts
53:19is a model he wants adopted across the state.
53:25Greg O'Toole has responded positively
53:27to appropriate care in the UK.
53:29Joseph Fay, his family hope
53:31he can soon come home to live.
53:35Some of these people are very severely mentally ill.
53:38Some people with brain injuries and dementias,
53:40their ability to look after themselves.
53:42These are people that should be in hospital,
53:45not in prison.
53:47Joseph Fay is currently in hospital in England.
53:52Communication with him can be hard to maintain
53:54and for his family, it's far from ideal.
53:57But coming home is not an option.
54:01It's the last thing in the world
54:04I would want for him or my mum
54:09because there's no mental health services.
54:15That's the fear.
54:18Otherwise my brother's coming home
54:19to go to prison.
54:22There is nowhere for him to go.
54:31The Irish Prison Service did not comment
54:34on specific cases
54:35but expressed its sincere sympathies
54:37to the deceased family members and friends.
54:40It said it provided medical units in prisons
54:43but demand for this accommodation has increased
54:46reflecting wider pressures
54:47on national mental health services.
54:50Acknowledging increasing demands
54:52in the prison service,
54:53Minister for Health Jennifer McNeill
54:55says she will continue working
54:57with the Minister for Justice
54:58to further improve and develop
55:00the provision of specialist psychiatric care
55:03for people in prison.
55:05The HSE said it is committed to ensuring
55:08that every person receives the right care
55:10in the right place at the right time.
55:12It acknowledges the issues raised
55:14in relation to HSE mental health services
55:16and regrets any impact
55:18this may have had
55:19on people and their families.
55:29Part 2 of RT Investigates
55:31the Psychiatric Care Scandal
55:32will be tomorrow night at 9.35
55:34here on One.
55:51The Psychiatric Care Scandal
55:52will be tomorrow night at 9.35
55:52will be tomorrow night at 9.35
55:52will be tomorrow night at 9.35
55:52will be tomorrow night at 9.35
55:52will be tomorrow night at 9.35
55:53will be tomorrow night at 9.35
55:53will be tomorrow night at 9.35
55:54will be tomorrow night at 9.35
55:55will be tomorrow night at 9.35
55:56will be tomorrow night at 9.35
55:57will be tomorrow night at 9.35
55:59will be tomorrow night at 9.35
55:59will be tomorrow night at 9.35
56:06will be tomorrow night at 9.35
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