A report out this week examining the death of a man in custody is the latest damning assessment of the management and care of vulnerable prisoners in Maghaberry Prison.
David O'Driscoll (30), who had a long history of mental health problems, was found dead in a cell just seven hours after arriving at the jail in August 2016.
A few hours before his death, his mother had telephoned the prison to alert staff about her son's welfare after he had called her at home and threatened to kill himself.
After making inquiries, the day manager on duty phoned her back and told her that her son was fine.
However, this was based on feedback from an officer at Bann House who had spoken to Mr O'Driscoll when he arrived on the landing. Nobody checked on Mr O'Driscoll after his mother's call.
Tragically, he died by hanging less than three hours later.
This disturbing case was investigated by the interim Prisoner Ombudsman Brendan McGuigan who said it was particularly distressing that having been reassured about her son's wellbeing, Mrs O'Driscoll was later told he had died.
It is clear from this report that a number of failings were identified in relation to Mr O'Driscoll, with specific concerns raised about his access to medication.
Even though a nurse had ensured medications were prescribed, at the time of his death they had not been administered.
Not for the first time in such a report, staff handovers and record keeping were criticised. On this occasion there was no written or verbal information provided to night staff about the need to monitor Mr O'Driscoll more closely.
These issues may seem rather basic but it is alarming how often we have heard about fundamental failings in the care of vulnerable prisoners.
The family of David O'Driscoll are entitled to feel let down by the prison service and must hope that the recommendations arising from this tragic case are implemented in full.
