Published Wednesday, 07 May 2014
The report said that the inmate gave out mixed messages to prison staff. (© UTV)
"Mr F" was a law student who had a history of depression and had previously attempted suicide in the community.
The Prisoner Ombudsman deemed that he had successfully concealed his distress from prison officers and healthcare staff, and that nobody in the prison realised he was so disturbed he would take his own life.
The report said a range of supports were put in place for Mr F, and it commended several features of good practice by NIPS and SEHSCT personnel.
However the Ombudsman made 19 recommendations to improve standards of prisoner care and help prevent serious incidents or deaths in the future.
Four previous Prisoner Ombudsman recommendations which were accepted by the NIPS - involving the Supporting Prisoner at Risk (SPAR) procedures and first aid training - were not fully implemented in this case.
The Northern Ireland Prison Service and the South Eastern Health and Social Care Trust have confirmed that due care and attention will be given to the recommendations that apply to them.
Prisoner Ombudsman Tom McGonigle said: "There were significant levels of intervention with Mr F during his time in Maghaberry.
"Several staff from a variety of disciplines demonstrated genuine care for his wellbeing, and while he saw a range of mental health specialists, his decision to hang himself could not have been predicted."
Responding to the Prisoner Ombudsman report, Prison Service Director General Sue McAllister said it was clear from the report that the prisoner in question was "a vulnerable individual with many troubles".
"He concealed his distress from prison and healthcare staff and his decision to take his own life could not reasonably have been predicted," she said.
"There are however, a number of important issues raised by the Ombudsman in relation to improving standards of prisoner care and helping prevent serious incidents or deaths in the future, and I will pay close attention to this in my overall consideration of the report in collaboration with the South Eastern Health and Social Care Trust."
Mrs McAllister added: "I would extend sympathy to the family in what have been difficult circumstances."
© UTV News