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A sex offender who killed himself in prison was not provided the level of support offered to other vulnerable inmates, a watchdog has found.
Prisoner Ombudsman Tom McGonigle highlighted a series of failings in how the prisoner, referred to as Mr E, was handled inside HMP Maghaberry in Co Antrim prior to his death in 2012.
Due to the nature of his offences the prisoner was being held on a landing reserved for offenders deemed at risk from other inmates.
He had no previous history of self harm or suicide attempts and staff told Mr McGonigle s investigators they were surprised he had taken his own life.
The ombudsman identified a number of areas of concern related to the nine weeks he spent in Maghaberry.
:: A communication breakdown meant that medications for depression and anxiety, which were prescribed in the community, discontinued once Mr E entered prison;
:: Cues such as Mr E s personal efforts to highlight his anxieties, and an apparent deterioration in his mental health, were missed;
:: He was not referred for psychiatric assessment, despite fulfilling criteria that indicated this ought to have been done;
:: Arrangements that existed to help vulnerable prisoners, such as the Prisoner Safety and Support Team and the Supporting Prisoners at Risk process were not implemented; and
:: Staff had inadequate training in the prison service s anti-bullying strategy
Mr McGonigle made 13 recommendations aimed at improving standards of prisoner care and helping prevent serious incidents or deaths in the future. Health services within Maghaberry fall under the responsibility of the South Eastern Health and Social Care Trust (SEHSCT).
Although Maghaberry had the necessary arrangements in place to support vulnerable prisoners, Mr E was not identified as needing them, said the ombudsman.
The NIPS (Northern Ireland Prison Service) and SEHSCT have accepted all our recommendations and made subsequent improvements that aim to improve the care of vulnerable prisoners in the future.
Prison service director general Sue McAllister acknowledged the ombudsman s report made for difficult reading .
Extending her sympathy to the family of Mr E, she said: The report into the death of this prisoner raises a number of issues of concern for both the Prison Service and the South Eastern Health and Social Services Trust, who have responsibility for health care within prisons.
The reality is that many people sent to prison have complex medical histories and are on medication in the community. That has to continue in custody. This tragic death reinforces the need for both the Prison Service and the Trust to improve processes and procedures to protect vulnerable prisoners.
We have accepted all 13 of the recommendations made in the Ombudsman s report to improve standards of prisoner care to help prevent serious incidents or deaths in the future.
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