Yet another damning report highlighting failings in the care of a vulnerable prisoner at Maghaberry jail raises questions about the effectiveness of reforms at this high security institution.
Earlier this month the Prisoner Ombudsman published harrowing details of the case of Sean Lynch, who gouged out his own eyes and inflicted other serious injuries on himself while prison officers watched.
This disturbing incident, which left Mr Lynch blind, took place in June 2014.
In November last year, prison inspectors were highly critical of conditions at Maghaberry, which was branded by one senior figure as the most dangerous jail he had ever visited.
Now Prisoner Ombudsman Tom McGonigle has published another alarming report, this time into the case of Patrick Kelly who died after overdosing on stockpiled prescription drugs while he was on remand at Maghaberry in February last year.
Mr Kelly was on medication for physical and mental health problems and recognised he was at risk, asking not to be allowed to retain his tablets as he was afraid he would take them all at once.
Unfortunately, after four days being supervised, he was allowed to hold his own pills and it appears he hoarded them and used them to overdose.
The report found prison officers and nurses overlooked crucial medical documents and failed to recognise Mr Kelly was at risk of self harm.
A total of 21 recommendations for improvement have been made by the ombudsman who also raised concerns with the South Eastern Health and Social Care Trust which is responsible for providing healthcare at the jail.
There is no doubt that looking after people with complex mental health issues in a prison setting is exceptionally challenging.
But questions do need to be asked about the failings that have been identified by this and other distressing reports.
We are repeatedly assured that steps are being taken to address concerns. Only time will tell if lessons have truly been learned.
