An inquest has opened at the Coroner's Court in Cork into the death of a 29-year-old man while he was in custody at Cork Prison two years ago.
Andrew Gearns, from Model Farm Road in Cork, was a heroin addict and was vulnerable and at a very low ebb in his life when he was imprisoned in September, 2020, according to his family.
He died by suicide some days later.
His family believe the father of two's life could have been saved with different care and intervention.
At a previous sitting of the court, Coroner Philip Comyn questioned why only a condensed version of CCTV footage captured after a red alert had been issued had been supplied.
Mr Comyn said when a death occurs in prison, 72 hours of CCTV footage from around that time should be retained.
He also asked why risk alerts raised in relation to Gearns' mental health had not been made available.
The Gearns family have also questioned the failure to supply the full 72 hours of CCTV. This has since been done and the footage has been examined by the family's legal counsel.
The family say they have waited more than two years for the inquest to begin. They say they want the inquest to be conducted properly.
It is understood a report has been completed by the Inspector of Prisons into Gearns' death.
Today the inquest heard that Aideen Gearns, mother of Andrew Gearns, called asking prison staff to keep a "closer eye" on her son after he made a disturbing call to her where he appeared to be hallucinating.
The inquest heard that she was contacted just over five hours later and told that he had made a suicide attempt, leading her to rush to hospital where he subsequently died.
The prison authorities at the inquest indicated that he was checked on 13 times on the afternoon of 28 September 2020. However, at 4.40pm he was found unresponsive in his one man cell in Cork Prison following a suicide attempt. He died at Cork University Hospital on 7 October 2020.
Andrew Gearns was not in a special observation cell during his time in Cork Prison.
Ms Gearns told Cork Coroners' Court that she received an alarming call from her son on the day of his suicide attempt.
She thought she would "never get him (Andrew) off the phone" so she could tell the prison that he was not making any sense on the phone.
"I dialled the prison straight away," she said. "Whatever he was saying he believed it. (The nurse) told me they were aware of it and that they would keep a 'closer eye' (on her son)."
The inquest heard that Gearns called his mother when he first entered Cork prison on 22 September. He seemed perfectly lucid during the first call.
However, Ms Gearns said that on 28 September at around 12pm, Andrew called her and started telling her a confusing tale about having been slashed in the face whilst out for a walk in Blackpool in the city. He also stated that he had gone for tea in Mayfield in the northside of the city.
Ms Gearns said that she initially did not realise that he was hallucinating as she had never seen him in this state.
However, Ms Gearns said when she contacted the prison she was reassured by a nurse that he did not have any injuries and they were aware of his condition. She hung up thinking that "a closer eye" would be kept on him.
Evan Gearns, the younger brother of Andrew Gearns, told the inquest that the father of two was very close to his mother. "The brown eyed boy" had such a good relationship with his mother that when they were younger if the siblings wanted something from her, Andrew was elected to ask for it.
Mr Gearns told Coroner Philip Comyn that the life of his brother had derailed when he became addicted to drugs.
Evan Gearns said that his brother had cried the week before he was imprisoned for a minor offence and wanted to turn his life around.
Andrew Gearns was "lost" and in a "very dark place" prior to his imprisonment, Evan Gearns recalled.
"But we thought he was in the best place and would be safe. He didn't want to be on drugs. He wanted help. We thought he would get the safe and proper medical treatment there."
Meanwhile, during his committal interview when he first entered prison Mr Gearns said that he was without suicidal ideation and had no mental health difficulties. Nurse Anna Lyons told the inquest that Andrew Gearns guaranteed his safety on two occasions during that interview on 22 September and denied any thought of self harm or hurting himself.
Ms Lyons said that he did not seem distressed or agitated and she did not think that he required special observation.
She made Covid protocol checks on Mr Gearns on 25 and 27 September. He was physically well but on the second check he told Ms Lyons that he had been slashed and stabbed on an outing.
A review with the GP was scheduled for the following day. Ms Lyons said although he appeared to be hallucinating he was "easily reassured". He knew where he was and appeared "orientated". He was scheduled for a GP visit and a check with a psychiatrist.
Ms Lyons said that she had carried out a previous committal interview for Mr Gearns in 2018 where she did place him on special observation because he had experienced suicidal ideation. In 2018 he had made a suicide attempt a week before entering prison.
Barrister for the family, Elizabeth O'Connell, SC, asked Ms Lyons why Mr Gearns own assessment of his suicide risk was the main reason why he was not placed in special observation.
Ms Lyons said that she made her own clinical assessment in addition to receiving feedback from the prisoner. Coroner Philip Comyn noted that there was "glaring inadequacies" in prison medical notes with "clear differences" between what was noted in the nursing notes and in the committal interview.
None of the differences were the fault of the individual nurse but were instead attributed to glitches in the system which are still being fixed.
The inquest also heard evidence from prison officer Paul Cleary who found Mr Gearns unconscious in his cell at 4.50pm on 28 September. He checked on Mr Gearns a number of times that afternoon and said that he seemed to be suffering withdrawal symptoms but appeared not to be a threat to himself or others.
Mr Cleary was not aware that Gearns had any history of suicide attempts. He said that Andrew Gearns seemed "defensive and afraid".
At one point during the day Mr Gearns told him that people at the window were trying to fight him. He also noted that the prisoner had not touched his dinner and when he asked him why he replied "how could I when my jaw is broken in five places?"
Cork Coroners Court also heard a statement from Mr Gearns' partner of 17 years, Amanda O'Callaghan, that he was put on Benzodiazepines for pain relief in 2016 following a car crash. He became addicted to the drugs.
Ms O'Callaghan said that Mr Gearns began to suffer suicidal thoughts. However, he entered treatment and returned to his usual self. His condition deteriorated again in 2019. He was using heroin and again entered treatment. However, he subsequently relapsed.
She said that when Andrew Gearns was put in prison, he rang on 25 September "sounding low".
The following day Mr Gearns called Ms O'Callaghan and said that he had been out for a walk in Blackpool and had been slashed with a blade in the face.
She stated that although he was in custody he believed this version of events. Ms O'Callaghan said he was not making any sense as she knew he was in custody.
On 28 September she was informed that he was in hospital following an incident. The inquest continues tomorrow.
