Frances McKeown, 23, was described as a "vulnerable inmate" with an extensive history of self-harming and psychiatric hospitalisation prior to her committal on remand in September 2010.

She had threatened suicide to prison and healthcare staff, as well as other prisoners before she took her own life in May last year, a Prisoner Ombudsman investigation found.

Despite making her intentions clear and knowing of her complex medical history, those in charge of her care did not request her medical notes and she did not see a psychiatrist until more than six months after her committal.

Issues were also identified in connection with the arrangements for prescribing and supervising her medication.

Prisoner Ombudsman Pauline McCabe said:"Frances was a troubled girl and her mental health issues were extremely challenging, but she responded well to therapeutic interventions and purposeful activity and it was clearly the case that she was at her best when she had human contact and things to do."

The Ombudsman said that at times, she was locked up "for too long", and found lockdowns during Easter and the Royal Wedding particularly hard.

On the night of her death she was also agitated by being locked down earlier than usual as a result of another prisoner's death that same evening. It is possible, given her fragile mental health, that this affected her.

Prisoner Ombudsman

The investigation also found that Ms McKeown was able to access a non-prescribed antidepressant while in prison that, combined with her prescribed medication, may have affected her mood at the time of her death.

The Ombudsman said the South Eastern Health and Social Care Trust, in charge of the healthcare of prisoners at Hydebank, have committed to reviewing arrangements for prescription and supervision of medication.

Ms McCabe added: "As a result of this investigation, and other death in custody reports of the Prisoner Ombudsman, the Trust has now reviewed the provision of mental health arrangements in all Northern Ireland prisons."

The fact that Ms McKeown's two children were in care and her sentence was longer than she expected added further stress.

"It is also to note that the investigation found evidence that Frances was bullied when it was believed that she had told prison staff that she had seen an officer kiss an inmate," Ms McKeown added.

However the investigation found that bullying was not a direct cause of Ms McKeown's death.

It is understood that Ms McKeown's husband, Brian McKeown intends to sue prison authorities as a result of the report's findings.

Prison Service Director General Sue McAllister expressed sadness at the circumstances surrounding her death,and said she intends to work with Governors to reduce the amount of lock downs to an "absolute minimum and only use them as a last resort".

"I will ensure that this is a priority issue for the new Governor at Hydebank Wood when an appointment is made," she said.

Responding to the issue of bullying in the prison she added: "As a Service we have a duty of care to all prisoners and must make all reasonable efforts to eliminate attempts aimed at creating a threatening or hostile environment for some. There are definite learning points in this report."