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:
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.”