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Stephen Doran, 69, from Newry, Co Down, was found dead in Maghaberry prison in June 2008.

Prisoner Ombudsman Pauline McCabe's report found that medics failed to spot a decline in the condition of the seriously ill prisoner who was awaiting sentence for a string of offences.

The inmate, who had chronic obstructive pulmonary disease (COPD), angina, pressure sores, problems with mobility and problems with maintaining his personal hygiene, died after his condition worsened while he was being held in the prison healthcare centre.

Mrs McCabe said: "My primary aims are to inform the coroner of my findings and to make recommendations which will help prevent similar deaths in future at Maghaberry or elsewhere in the Northern Ireland Prison Service.

"Mr Doran was in a poor state of health when he was committed to Maghaberry and he was immediately transferred to the prison healthcare centre, where he died four days later."

The prisoner was awaiting sentencing after being convicted of 37 counts of indecent assault against adult males.

The review of his case found he had been treated by staff at the medical centre but they failed to spot a decline in his condition.

"A critical feature is that Mr Doran was locked up from the afternoon on June 5, 2008 until next morning with no appropriate clinical observations having been made."

Staff had tended to the prisoner in their care but a lack of monitoring, errors in care and the availability of facilities contributed to the death.

The Prisoner Ombudsman's recommendations include a plan to have facilities reviewed in conjunction with the South Eastern Health and Social Care Trust.

The Ombudsman said: "My recommendations have all been accepted by the Northern Ireland Prison Service and the South Eastern Health and Social Care Trust, who accepted that the standard of care and treatment of Mr Doran fell short of what was normally expected."

© Press Association