The mother of a man who was found dead in his cell nearly two years ago told staff he had threatened to kill himself a few hours before his death, according to a new report.
David O'Driscoll died on 12 August 2016 at Maghaberry Prison after he was found in a cell in the jail's committal house, seven hours after arriving at the unit.
A few hours before the 30-year-old's death, his mother phoned the prison to raise concerns about her son's welfare because he had called her home and threatened to kill himself, the Interim Prisoner Ombudsman's report said.
After making inquiries, the day manager on duty returned Mrs O'Driscoll's telephone call and reassured her that her son was fine.
Mr O'Driscoll died later that evening.
The investigation identified that no one had spoken directly to Mr O'Driscoll about the call he had made to his mother's home, and the reassurance given to Mrs O'Driscoll was based on earlier interactions an officer on the committal landing had with him.
Interim Prisoner Ombudsman for Northern Ireland Brendan McGuigan said: "It is particularly distressing in this case that, after being reassured by the prison about her son's well being, Mrs O'Driscoll was later told that he had died."
Mr McGuigan continued: "I wish to impress on prison staff the importance of staff handovers and record keeping which in this case fells short of the standards required.
"It is clear that some aspects of Mrs O'Driscoll's telephone call could have been managed better and there was no evidence that a number of measures the manager asked to be put in place were completed.
"The investigation identified an inadequate handover from NIPS (Northern Ireland Prison Service) day staff to night staff and poor record keeping, which regrettably is a recurrent finding in Prisoner Ombudsman death in custody investigations."
A clinical review conducted as part of the investigation raised potential concerns around the continuity of Mr O'Driscoll's access to medication from his time in custody.
Following his arrival in prison, a committal nurse identified that he required medication and made arrangements for this to be prescribed.
The prescription was dealt with by an out-of-hours GP service and two medications were prescribed, but at the time of his death Mr O'Driscoll's medication had not been administered.
A separate clinical review of the resuscitation attempt concluded that it was commenced promptly and carried out in as effective and efficient a manner as possible after Mr O'Driscoll was found.
The report makes 11 recommendations for improvement - the majority of which have been accepted by NIPS and South Eastern Health and Social Care Trust.
Head of the Northern Ireland Prison Service Ronnie Armour said: "I want to extend my sympathies to David's family. I very much appreciate how difficult the findings of this report will be for them and, on behalf of the Prison Service, I want to apologise for the fact that David died in our care.
"It is important to recognise the difficult and challenging circumstances that prison staff encounter every day. In the last year alone, prison officers at Maghaberry Prison have saved 12 lives."
Mr Armour added: "However, today's report clearly highlights the events leading up to David's death and, in doing so, rightly focuses on a number of failings in our procedures. I want to assure the family that we have, and will continue to learn from this tragedy."