A Lithuanian national who took his own life in Northern Ireland's top security prison had attempted to die by suicide a week previously - but staff were not told, a report has found.
Laurynas Steponavicius (23) was found dead at Maghaberry in January 2016 - seven weeks after being remanded into custody.
A report published today following an investigation by the Prisoner Ombudsman noted Mr Steponavicius had claimed he was contemplating suicide, and had attempted to take his life.
But nobody passed the warnings on to prison officers or healthcare professionals because they did not believe he was serious.
Today's report makes four recommendations, all of which have been accepted by the Northern Ireland Prison Service and South Eastern Health and Social Care Trust.
Mr Steponavicius had been remanded to Maghaberry Prison on January 5 2016.
He was found hanging on February 11 2016, and died 11 days later at an outside hospital.
This was his first time in custody, and a clinical reviewer from the Prisoner Ombudsman's office was satisfied he did not exhibit any evidence of mental illness or excessive distress during his first few days in Maghaberry.
Mr Steponavicius had asked to see police officers while in prison and they visited him on the day before he died. He told them that he felt safer in Maghaberry than in the community. Despite this assertion, he met with a senior prison officer and a nurse the next day and requested a transfer to another cell.
He was anxious as he had disclosed his meeting with the police to his cellmate, who was also his co-defendant.
The senior officer promptly initiated the request for a transfer, but it did not happen prior to his death, just two hours after they spoke with him.
The senior prison officer and nurse provided differing accounts about whether Mr Steponavicius disclosed thoughts of suicide to them.
After he died, it transpired that Mr Steponavicius had previously suggested to fellow Lithuanian prisoners and to his girlfriend that he was contemplating suicide; and that he had made an unsuccessful attempt about a week before he died.
However, nobody passed this information on to prison officers or healthcare professionals because they did not believe he was serious.
The report states that as a young man in a foreign prison, Mr Steponavicius was in a higher than average risk category.
He also appeared to be stressed by the relationship with his girlfriend, and by his isolation as he did not have any visitors or contact with family during his time in Maghaberry.
The Prisoner Ombudsman's clinical reviewer was satisfied that the resuscitation process was well-led and well-conducted by the Prison Service and South Eastern Health and Social Care Trust (SEHSCT) staff when Mr Steponavicius was found.
This report makes four recommendations for improvement, all of which have been accepted.
These include proposals to the Prison Service that foreign national prisoners should be allowed to make a free international call upon committal if their designated next of kin does not live locally.
Among the recommendations for the SEHSCT was to ensure that staff have an awareness of factors which put prisoners at higher risk of self-harm or suicide, and ensure they look beyond prisoners' self-report.
Prisoner Ombudsman Tom McGonigle said it was a tragic episode.
"This is a sad case of a young man who ended up in prison in another country, far from his family," he said.
"He had prospects for bail but several matters were stressing him, some of which were not known to the authorities until after he died, and he felt he had no-one to turn to for support.
"I extend my sympathy to his next of kin for their untimely loss."