A prisoner killed himself unobserved by a CCTV monitoring unit where prison officers watched TV, chatted, drank tea and, in one case, rested in a makeshift bed.

Colin Bell made repeated suicide attempts over the course of a harrowing final hour in his cell, while staff at Maghaberry jail failed to carry out checks on him at the required 15-minute intervals.

He was not spotted until 38 minutes after his fourth, successful, attempt to hang himself.

Mr Bell also tried to contact the Samaritans 73 times in a 30-hour period before his death via a link-up facility in his cell. Almost all of these calls are believed to have resulted in an engaged tone.

The full, highly disturbing facts in the case are spelt out in a special report published today by Prisoner Ombudsman Pauline McCabe.

The report listed a catalogue of serious failings by staff on the night in question and also recommended disciplinary investigations for two Maghaberry Prison chiefs.

Thirty-four-year-old Mr Bell was serving a sentence for an arson attack in which a man was burned to death.

He committed suicide last summer in his special CCTV monitored observation cell, where he had been placed after a series of self-harm incidents.

Among the facts established by Ms McCabe’s damning inquiry into the events of July 31 were:

• CCTV footage showed that over a period of 14 minutes from 10.57 pm, Mr Bell was holding a ligature and made three attempts to hang himself. His fourth, successful, suicide attempt was at 11.41pm. Before this, he had stood in front of the CCTV camera and very deliberately placed the ligature over his head.
• Even before his first attempt and between his third and fourth attempts, he could be seen walking around his cell with a ligature in his hands.
• During the course of the evening of 31 July, Prison Service officers on his landing did not carry checks of his cell at the 15-minute intervals required by Prison Service policy.
• The officer responsible for viewing CCTV footage from a POD unit also did not carry out or record checks at the 15 minute intervals required by policy. The POD is the key control unit where all prisoner movement is managed and logged.
• Landing officers who should not have even been in the POD, and the night custody officer stationed in the facility, can be seen on CCTV footage in the POD chatting, smoking, watching television and using the computer.
• A senior officer made a supervisory visit but did not check the CCTV or enquire about the two prisoners in the observation cells.
• While alone in the POD, its night custody officer made and briefly lay down in a makeshift bed at 11.27pm and again at 12.17am.
• At the point Mr Bell was actually taking his own life, this officer and a colleague were in the POD unit chatting beside a computer, having made a cup of tea.
• After the alert was finally raised by a prison officer checking the cell, the POD unit officer folded up his mattress and put it away.
• Between 4.12pm on July 30 and 10.21pm on July 31, Mr Bell pressed the Samaritans’ call button in his Safer/Observation Cell 73 times. “Evidence suggests that around 63 of these presses resulted in an engaged tone,” the Ombudsman stated. The report also revealed that the Director of Samaritans Ireland has initiated “a comprehensive review” on the case.
• On two nights shortly before his death, Mr Bell wrapped toilet paper around his feet in an apparent attempt to keep warm. His blanket had been removed for his own safety.

The Ombudsman’s report cited Prison Service policy, which makes clear Governors must take “personal responsibility for the implementation of the Policy on Self-Harm and Suicide Prevention within their establishments”.

Today’s report stated: “There were failures by the Governing Governor and Deputy Governor of Maghaberry Prison in respect of Colin’s care and the implementation of prison rules and policies.”

The Ombudsman recommended that Governor Alan Longwell and his deputy Steve Davis are each subject to a disciplinary investigation. It’s believed a disciplinary inquiry of this nature would be the first of its kind at any UK jail.

Several Maghaberry prison officers were suspended last year, amid an internal investigation into night guard arrangements.

There has been media speculation about a number of officers being caught sleeping while on duty. However, today's Prisoner Ombudsman’s report only referred to CCTV evidence of one officer lying down.

Ms McCabe’s report also stated that some night custody officers have second and even third jobs. “This may have implications for their capacity and fitness to perform the duties required by the Prison Service and, in particular, their ability to have appropriate rest.”