Report on tragic jail overdose

Pauline McCabe said: "Mr Gilmore died as a result of an accidental drugs overdose resulting from a combination of prescribed and illicit drugs which had been brought into the prison."

From her investigation, Pauline McCabe made a total of 31 recommendations to the Northern Ireland Prison Service and the South Eastern Health & Social Care Trust, including 15 early recommendations which were delivered in July 2009.

It was the view of the Ombudsman that the implementation of these early recommendations might help to prevent further deaths.

The recommendations related to: the supply and control of drugs at Magilligan; the response to serious incidents; the management of prisoner drug abuse

Out of the 31 recommendations made to the Prison Service, 21 have been accepted, two have been partially accepted and eight have not been accepted.

The Prisoner Ombudsman intends to have further discussions with the Prison Service in respect of the 10 recommendations not accepted or partially accepted.

She will also monitor the implementation plan for those recommendations.

Commenting on the Report, Mrs McCabe said, ""My investigation reports are intended to both provide important learning for the Prison Service and provide the family with answers to their questions.

"Deaths in prison custody are sad events and have a significant impact on everyone involved.

"This case is particularly tragic because Mr Gilmore died following a home visit which was to prepare him for his early release, scheduled for just 19 days later.

"I hope the learning highlighted in our investigative reports will help to reduce the possibility of any similar death in future in Magilligan Prison or elsewhere in the Northern Ireland Prison Service.

"This case and several others recently reported by my office have highlighted again the serious issue of the availability and use of illicit drugs in prison."

Pauline McCabe made a commitment when she took up post in September 2008 to publish all death in custody investigation reports. In line with the Prisoner Ombudsman Terms of Reference, a copy of the Report has also been sent to the Coroner.