Report into prisoner's hanging
A prisoner hanged himself in a Northern Ireland jail after warders dismissed claims he had taken an overdose.
Geoffrey Singleton, 42, had attempted suicide in the community and there was one case of self-harm while in custody, a review said.
He had a lengthy history of abusing drugs and had spent a considerable amount of time in prison since 1993.
Shortly before he died he told the authorities he had swallowed a package of heroin but it was suggested he had manufactured the claim, which turned out to be false.
His death in May 2013 was preceded by hospital treatment and the watchdog said part of the Prison Service response was inappropriate.
Ombudsman Tom McGonigle said: "Mr Singleton's death was unpredictable. While he had attempted suicide in the community, there was only one incident of self-harm in prison and staff and prisoners who knew him were very surprised when he took his own life.
"His family appreciated the support they subsequently received from Maghaberry's chaplaincy team."
Singleton had been returned to prison after problems adhering to a licence condition surrounding where he could live.
He had overdosed on heroin before returning to prison, and shortly after committal disclosed that he had swallowed a package of heroin. There was a suggestion he manufactured the situation in an attempt to resolve his medication issues, the report said.
He was subsequently taken to an outside hospital but discharged himself and returned to Maghaberry.
Tablets were found in the van that was used to transport him, though it is not known if he had taken any of these, the review said.
The report said: "Poor communication from the hospital meant radiological evidence that he had actually swallowed something was not made known to the governor, who then inappropriately placed Mr Singleton in a dry cell in the Care and Supervision Unit (CSU).
"A care plan should have been put in place to address the possibility of a toxic overdose from leakage of heroin in the gut."
Ultimately his post-mortem examination revealed that, with the exception of cannabis, which could have been taken before he was returned to prison, all of the drugs found within Mr Singleton's system were in line with the prescribed medication that he had recently received.
Prison Service Director General, Sue McAllister said: "The recommendations made for improvement have been accepted and will be implemented by the Northern Ireland Prison Service.
"We will continue to work closely with our healthcare colleagues in the South Eastern Health and Social Care Trust to ensure that lessons are learned and that all prisoners continue to receive a high quality of care and support."