A prisoner died from a cocktail of prescription and illicit drugs after taking almost a week's supply of his allowed medication in just one day, a report said.
Patrick Duffy, 49, was poisoned by anti-depressants and other tablets at Maghaberry, Co Antrim, a year ago. He had an increased risk of abuse and had self-harmed but despite this was issued with a significant number of pills by prison doctors the day before he died.
Prisoner Ombudsman Pauline McCabe said his self-referral to addiction services suggested he recognised a problem with his dependence on drugs yet appropriate consideration was never given to a prison medic or the mental health team reviewing him.
She said: "The Prison Service needs to be much more effective in dealing with drug trading and misuse, in addition to the associated culture of bullying created by such practices. Curbing the supply of drugs is highly dependent upon reducing demand and it is therefore essential that greater priority is given to purposeful regimes and therapeutic interventions."
Ms McCabe said the six month waiting time for a first appointment with the alcohol and drug educational services was entirely unsatisfactory.
"It is not to be underestimated that the implications of such insufficient provision are far-reaching and could ultimately undermine prison reform through the resulting negative impacts on the intended role of the prison officer, the delivery of purposeful activity and the potential to achieve effective rehabilitation and resettlement," she added.
Mr Duffy, from Derry, was found dead in his cell at Foyle House in Maghaberry high-security prison shortly after midnight on June 23 2011. He was due to appear in court that morning and faced charges of criminal damage and assault but was expected to get bail. The charges were withdrawn.
The Ombudsman`s report said: "His cellmate reported that Mr Duffy was looking forward to leaving the prison to be with his partner and family. No evidence was found that Mr Duffy intended to die."
Justice Minister David Ford said the tragic case underlined the importance of the effective management of the use of prescription drugs within prison. He said of the 14 issues of concern highlighted in the report, there are seven for the Prison Service to address.
"It is a reality that many prisoners who come into the care of the Prison Service and the South Eastern Trust are on various forms of medication in the community," he said. "That medication cannot be removed when they are sent to prison but there is an obligation on the trust and the prison service to manage their medication effectively, with continuous monitoring."