The two men should never have been placed in the same cell together, the Commission of Investigation into the 2006 killing has concluded.
The report by Grainne McMorrow SC has also found that the dead man, his killer Stephen Egan and five other men they were sharing a basement cell with when the murder occurred were all being accommodated in a manner that breached their human rights.
She also found no spot checks had been carried out on the cell on the night Mr Douch was killed, with his lifeless body not having been discovered until the cell was opened the following morning.
Overcrowding at the jail had “completely undermined” the prison staff’s ability to facilitate Gary Douch’s request to be housed away from the main prison population because he feared for his safety.
It found Egan was a violent, mentally ill and troublesome prisoner who was transferred from Cloverhill Prison to Mountjoy Prisoner in exchange for another inmate just two days before he killed Mr Douch.
That exchange was “sweetened” by Cloverhill having agreed to take a group of prisoners from Mountjoy to ease overcrowding there.
However, the staff in Mountjoy who agreed to take in Egan were unaware the authorities at Mountjoy had refused to take him in when he had been released from the Central Mental Hospital just two weeks earlier.
Despite being a violent prisoner and having just previously been acutely psychotic when taken from the prison system to the Central Mental Hospital, there was no medical consultation around his transfer between the two jails.
His medical files did not travel with him and nor did his medication, meaning he was not in receipt of his medication in the days leading up to the murder in the early hours of August 1st, 2006.
When he began to verbally display the same signs of psychosis and hallucinations in Mountjoy as he had had done in the Central Mental Hospital, this apparently went unrecognised and meant he was locked in a communal cell, where he murdered Mr Douch.
“In particular, Mr Egan displayed the same delusional preoccupations with “the Beast” and “rapes” as well as other symptoms of psychosis in holding cell 2 on the 31st July/1st August that he had displayed previously when unwell,” the commission notes.
It also concludes that attacks which Egan was involved in within the prison service – such as setting fire to a padded cell and trying to strangle a prison officer during a transfer – were never fully investigated with a view to shaping better treatment for him.
The report also reveals that the prison service was so keen to continually transfer the troublesome, violent and mentally ill Egan that no one group of staff or facility ever took ownership of his care.
The commission also concludes that, given the seriousness of his mental health issues, Egan should never have been transferred from the Central Mental Hospital on July 14th, 2006, back into the prison system, just nine days after admission to the hospital.
It says the transfer to Cloverhill occurred despite the Central Mental Hospital knowing that once Egan was back in the prison system, it would lose any influence over his care.
After just two weeks in Cloverhill he was transferred to Mountjoy, and within 72 hours he had killed Mr Douch in a basement holding cell.
Staff at Cloverhill are excoriated in the new report for having sought to offload Egan from their care because he was so difficult, and for placing him in the overcrowded environment of Mountjoy that they knew was not well placed to care for him.
“The management at Cloverhill Prison exhibited what this commission regards as a reckless disregard for the health and safety of Stephen Egan in transferring him to Mountjoy Prison without any consultation with his doctors or with the psychiatric in-reach service,” the report states.
It continues: “In selecting Stephen Egan for transfer, Cloverhill also exhibited a reckless disregard for the health and safety of staff and prisoners at Mountjoy Prison, which they knew was under severe pressure from overcrowding.
“He was wholly unsuitable for transfer, given that he was a prisoner with known violent history, still under psychiatric care and on anti-psychotic medication, recently discharged from the Central Mental Hospital.
“The transfer also involved moving Stephen Egan from the safety of a high observation single cell on Cloverhill’s D2 wing to Mountjoy, when they knew, or could reasonably be expected to have known, that he would not be accommodated in anything approximating the facilities available in D2.”