The Minister for Justice, Equality & Defence, Alan Shatter TD, and Minister of State, Kathleen Lynch TD, have published the Report of the Commission of Investigation into the death of Gary Douch and the Response by the Director General of the Irish Prison Service, following its consideration by Government yesterday. 

The Commission, which was established under the Commission of Investigation Act 2004, submitted its report to the Minister on 5 February, 2014 and can now be published following confirmation from the Office of the Attorney General, the Director of Public Prosecutions and the Garda Síochána that publication would not prejudice any criminal proceedings.

The Commission inquired into the circumstances surrounding the tragic death of Mr. Gary Douch in Mountjoy Prison on 1 August, 2006.  Ms Gráinne McMorrow SC was appointed by the then Government as Sole Member of the Commission in June, 2007.   The Commission was initially expected to report by the end of that year but was unable to do so due to ongoing court proceedings regarding the man accused of Mr Douch’s murder, Stephen Egan, who was subsequently found guilty of manslaughter on grounds of diminished responsibility.

Minister Shatter and Minister Lynch together with Michael Donnellan, Director General of the Irish Prison Service, today met with the late Gary Douch’s mother and other family members. They discussed with them the Report and apologised both on behalf of the State and the Prison Service for the catastrophic failures which resulted in Gary’s death.

Commenting on the Report Minister Shatter said "I begin by offering my sincere sympathy to the mother and family of Gary Douch who tragically lost his life in Mountjoy Prison in August 2006.  The Commission of Investigation’s conclusion is clear - his death was avoidable and should not have happened.   It is only right that I apologise on behalf of the State and Irish Prison Service to the family of Gary Douch.  I hope this report helps to clarify for them what happened that night, what should have been avoided, and what can be learnt to ensure there is no possibility of this happening again.  In this regard my colleague Kathleen Lynch and I, together with the Director General of the Irish Prison Service, believe it to have been of considerable importance that we met with Gary’s mother and other family members today ahead of the report’s publication. 

"I welcome this report and would like to thank Ms Gráinne McMorrow SC and her team for putting together an insightful and detailed account of what happened.  While much has been done in the intervening years to address the issues that arose, we now also have a road map for the future to learn from this tragedy and find new ways to prevent it happening again."

The Commission’s Final Report contains several conclusions relating to the management, medical treatment and psychiatric care of Stephen Egan prior to and subsequent to the killing by him of Gary Douch.   While overcrowding was a factor, many of these conclusions are highly critical and point to systemic management failures on the part of prison management and the psychiatric services.  

The Commission has redacted the names of certain individuals in accordance with section 32(3) of the Commission of Investigations Act, 2004.   The Commission decided, in the public interest, to redact information which could endanger certain prison staff up to and including the rank of Chief Officer or impede their ability to perform their functions within the prison system.  For similar reasons, the Commission also decided to redact the names of medical personnel including nurses, doctors, community psychiatric nurses, psychologists and psychiatrists; and individuals who gave information to the Commission on a confidential basis.

Next Steps
The Commission recognised the many significant and essential improvements which have been put in place since the death of Gary Douch including reduction in overcrowding, investment in prisoner accommodation, improved services to prisoners, the introduction of committal assessment procedures, healthcare assessment and provision of health services. The Commission expresses the view that the actions identified in the current Irish Prison Service Strategic Plan will also substantially transform the prison service.  The Commission believes that all ‘alternatives to custody’ options need to be considered, to reduce the prison population to safe levels.   It adds that the implementation of alternative sentencing options could deliver measureable benefits all round including significant cost benefits.

Minister Shatter said "I have long been committed to real alternatives to custody and am confident that the IPS Strategic Plan is making a very real and considerable difference.  Much has changed for the better in the way our prison system is run and administered since Gary’s tragic death. The Response by the Director General of the Irish Prison Service, published today, outlines the comprehensive programme of modernisation and reform that has taken place within the Prison system particularly during the past number of years.   It is widely acknowledged that Mountjoy Prison is now unrecognisable.

"All prisoners in Mountjoy Prison now occupy single-cell accommodation, with the exception of a relatively small number of prisoners in the Separation Unit. Significant investment in the prison infrastructure, including major redevelopment of Mountjoy Prison, has addressed the twin problems of overcrowding and poor physical conditions in our prison. Significant improvements in the treatment and management of mental illness have been implemented in Mountjoy which have been recognised by the World Health Organisation, as well as other important measures across the prison estate.   I am conscious however that more always needs to be done and we must all learn from the lessons to be found in this Report.  We must ensure everything possible is done to fully address all of the issues raised.

"With that in mind, I already have in place an inter-departmental group which is examining the issue of people with mental illness coming into contact with the criminal justice system.  That group, which I established together with Minister of State Kathleen Lynch has been examining many of the issues raised in the report.  I have decided to refer the Commission’s report to that group bearing in mind their deliberations to date and requested them to consider the recommendations in a cohesive way and to report back to myself and Minister Lynch within three months.  

"I am confident this will build on the work already done, continue the progress being made in this important area, and ensure that Gary’s enduring legacy will be that nothing like this can happen again".

Expressing her sincere sympathy with the mother and family of Gary Douch, Minister of State Kathleen Lynch said " I too welcome the publication of this report and hope that it will bring some closure for the family.  I hope that the closer working arrangements now in place between the Forensic Mental Health Service and the Irish Prison Service will ensure that tragic incidents such as this should not occur in the future.

"I would also like to thank Ms Gráinne McMorrow SC for submitting a report which tells us what happened and makes a number of recommendations including some in relation to the Forensic Mental Health Service.  Those recommendations will now be considered by the inter-departmental group which I and Minister Shatter established.  That group will give full consideration to the report’s recommendations and I look forward to receiving their report within 3 months"

The report of the Commission of Investigation together with the response of the Irish Prison Service is published on the Department’s website:

1 May 2014


Notes to Editors:

Gallagher Shatter Solicitors have for some time acted as legal advisers to the Prison Officers Association (POA) and have represented members of that Association and did so before the Commission of Inquiry. Minister Shatter has never been personally involved as a legal advisor to the POA nor was he involved as a member of the firm with the Commission of Inquiry. However, upon his appointment as Minister he was of the view that it was appropriate that any matters arising in relation to the Commission of Investigation and any issues arising from cases or situations in which Gallagher Shatter Solicitors represented the POA should be dealt with by the Secretary General of the Department.  This was to ensure that there could be no suggestion of any nature of a conflict of interest.    As the Commission of Investigation Report is now published, it is appropriate that the Minister proceeds to act on its recommendations and to address issues arising out of the Report.