A FINDING that “errors and omissions” were made by the South Eastern Health Trust in the care of a Fermanagh man who took his own life in prison has been welcomed by his family, who waited five years for an inquest into his death to be conducted.

Niall Oliver Leonard (37), who lived in Carrowshee Park, Lisnaskea, was found dead in his single cell in Maghaberry prison on July 7, 2012.

The law student had been remanded in custody over a month prior to his death, following an allegation that he had assaulted his partner.

During his time in custody, Mr. Leonard made repeated threats that he would kill himself and was assessed by medical staff on a number of occasions.

His mother, Rita, also raised her own concerns about her son’s mental state with prison authorities.

An inquest into his death was held at Laganside Court Complex in Belfast last week, presided over by Coroner Joe McCrisken.

A jury was required as the death had occurred in custody.

After the evidence was heard, the jury were satisfied beyond a reasonable doubt that the deceased had taken his own life. His cause of death was given as hanging.

They further found that “errors and omissions” were made by the South Eastern Health and Social Care Trust in the care of Mr. Leonard.

“We believe inappropriate and inadequate actions were taken which ultimately contributed to his death,” the jury stated.

Speaking to the Impartial Reporter yesterday (Wednesday), the solicitor who represented the Leonard family at the inquest, Padraig O Muirigh, said that they welcomed the findings of the jury.

On behalf of the family, Mr O Muirigh said: “They have waited five years since his death for the inquest to be conducted. This unacceptable delay added to their distress at his loss.

“Rita Leonard, mother of the deceased, had from the outset expressed grave concerns in relation to the care of Niall whilst in prison.

“These concerns were communicated to the prison before his death and subsequently to the appropriate authorities who investigated this matter.”

The Belfast-based human rights lawyer said that the case raised “wider concerns” about the care of prisoners with mental health issues in the prison system.

He said: “Too often vulnerable prisoners fail to receive adequate levels of care.

“Whilst it is too late for Niall, my clients hope that the appropriate lessons can be learnt from his tragic death.”

Mr O Muirigh added: “Finally, my clients would like to thank the jury and the Coroner for the diligent and sensitive manner in which they conducted the inquest.”

In a statement released to the Impartial Reporter this week, the South Eastern Health and Social Care Trust extended “sincere sympathy” to Niall Leonard’s mother and his extended family.

A spokesperson for the Trust said: “The Trust acknowledge the jury’s findings in the recent inquest relating to Mr. Leonard’s death in 2012.

“The Trust continuously strive to implement all recommendations to improve prison healthcare and have made significant improvements in the delivery of healthcare following the transfer of responsibility from the Northern Ireland Prison Service to the South Eastern HSC Trust in 2012.”

Mr. Leonard, who was studying law at a technical college in Letterkenny at the time of his death, had previously worked as a joiner.

On May 6, 2012, several weeks before he was remanded into custody, he had attempted to take his own life by taking an overdose of medication.

After his remand, Mr. Leonard expressed suicidal feelings and was placed on the Supporting Prisoners at Risk (SPAR) programme.

However, at the end of May 2012, a decision was taken to end his SPAR placement.

He was subsequently assessed by a mental health nurse.

“Anti-depressant medication was prescribed to Mr. Leonard without being assessed by a doctor. It was a ‘repeat prescription’ given without any medical records consulted,” the Coroner stated in the inquest findings.

During his time in custody, Mr. Leonard also saw a mental health nurse as part of an assessment for Eye Movement Desensitisation and Reprogramming (EMDR) therapy.

After her son was transferred from a double cell to a single cell, Rita Leonard contacted landing staff at the prison to express her concern over the move.

Several weeks earlier, she had contacted Lifeline and reported that she was concerned her son might kill himself.

This message was passed on to the prison and Mr. Leonard was subsequently assessed by a psychiatrist, who increased his dosage of anti-depressants.

On the day of his death, Mr. Leonard was again seen by a mental health nurse, who noted that he seemed “upset” but was not suicidal and making plans for his future.

At 5pm that evening, several hours before he was found unconscious in his cell, he sustained a cut to his hand, which he claimed had occurred as he tried to extract tobacco from a cigarette.

A nurse that treated him noted that he denied any thought of self-harm or life not worth living.