Prison bosses did not adequately investigate the bullying of an inmate in Northern Ireland who took his own life, it has been revealed.
Samuel Carson, 19, from Belfast, was repeatedly targeted for verbal and physical abuse at Hydebank Wood Young Offenders' Centre because he was accused of sex offences involving a minor.
He was struck on the head with a ceramic ashtray, punched and threatened with having his throat cut, a report by Prisoner Ombudsman Pauline McCabe said.
Despite this, numerous other threats reported against the troubled victim were not investigated, the inquiry found.
Mr Carson told his mother, Sylvia Carson: "There was a bounty on my head."
His family said his treatment before he hanged himself from a belt in his cell in May last year destroyed his spirit.
"Bullying of a vulnerable person with serious health issues and not adequately supervised in a supposedly secure and safe environment is shameful," they said.
He and his family were threatened by loyalist paramilitaries in the South East Antrim area and he was unable to find a place to live while released on bail because of the danger posed by members of the community who believed he was a rapist. Rape charges were later withdrawn.
Mr Carson had split up with his girlfriend and mother of their two young children, there was a history of domestic abuse, and he believed he would not be able to see his young daughter.
His decision to hang himself may also have been influenced by his use of prescription medication for depression which can encourage suicidal thoughts, the report said. It also suggested he may not have intended to kill himself, but to register a "cry for help" in the mistaken belief somebody was about to check his cell.
The dossier said: "It is one possibility that after months of verbal and physical bullying Samuel decided that he could not take another night of the same abuse."
The report recorded that bullying investigations were abandoned in the jail when Mr Carson withdrew allegations due to concern he would be subjected to more severe abuse. He was assaulted in 2010 by inmates whom he had previously told staff a number of times were bullying him.
Investigations were not effective and there was no evidence that recommended action was implemented by staff, the 151-page document added.
The ombudsman said: "Regrettably, this investigation has again highlighted that the Prison Service does not properly implement its own bullying policy and, in particular, does not adequately investigate bullying incidents and take appropriate action.
"Although there is evidence that, on numerous occasions, prison officers themselves recognised, or were alerted to, prolonged verbal and physical bullying of Samuel, little was done to address the actions of the perpetrators.
"There cannot be any acceptance that bullying in prisons is inevitable or will be tolerated. A failure to robustly address bullying within prisons can lead to all too tragic consequences."
The investigation also highlighted inadequate monitoring of his mental health and medication.
He was moved around prison landings following repeated complaints of bullying, self-harming and threatening to commit suicide. He later admitted the threat to kill himself was a way to get off the landing and some prison officers believed he was attempting to "manipulate" the system, the report said.
The security department concluded: "Inmate Carson has now quite a collection of listed enemies and it is difficult to keep him totally safe."
Some landing records were lost and security meetings with the victim were not noted. Information supplied by inmates to security was not regularly recorded. The ombudsman raised 28 areas of concern with the authorities.
Despite this, there were cases of good care, with prison officers giving him tobacco and calling his girlfriend for him shortly before he died.