Delays in reaching an unconscious prisoner in the wake of a suicide bid may have contributed to the serious brain damage he suffered, a watchdog report has found.
The 30-year-old convicted sex offender, who had a history of psychiatric problems, self-harm and alcohol abuse, was being held in the Care and Supervision Unit (CSU) at Maghaberry prison in Co Antrim when he tried to hang himself in his cell in February last year.
As part of supervision measures for patients deemed to be at risk, he should be been checked on every 15 minutes.
But an investigation by Prisoner Ombudsman Pauline McCabe found that when the prisoner - referred to as Mr C - was discovered unresponsive in his cell by an officer, 29 minutes had elapsed from the last time he was observed through the door flap.
Ms McCabe said it took a further five minutes to get the cell opened, as a senior officer was also required to be present under security protocols.
Resuscitation was commenced with the assistance of prison nurses and after 10 to 15 minutes Mr C had begun to breathe again. Paramedics arrived almost half an hour after the prisoner was found.
Ms McCabe said there had been a four and half minute delay requesting an ambulance due to "an unfortunate misunderstanding" of a radio message sent by the senior office at the scene.
While the prisoner ultimately survived the episode, he was left with complex physical disabilities and cognitive impairment caused by severe brain injury, including an inability to speak and communicate basic needs. He is now cared for in a nursing home.
Ms McCabe said the care Mr C had received in the CSU had been the most thoughtful he had experienced during his last stint in prison and noted that prior to the delay around the suicide bid he had been checked regularly as required.
"This being the case, the mistake made by the sole officer in the CSU who missed Mr C's final observation was most unfortunate," she said.