PRISON OFFICERS were chatting, watching television, using a computer and smoking while on a CCTV monitor closeby a prisoner could be seen preparing to take and ultimately taking his own life by hanging, according to a damning report published yesterday.
That same night, a prison officer charged with monitoring the CCTV assembled and used a makeshift bed in the special unit of Maghaberry Prison that observes vulnerable prisoners, the inquiry by Prisoner Ombudsman Pauline McCabe also found.
The North's direct rule prisons minister Paul Goggins promised yesterday that her report - which recommends disciplinary action against prison governor Alan Longwell and his deputy Steve Davis - would be a "watershed" moment in improving prison services.
The report examines how and why the prisoner Colin Bell, who had a history of self-harm, was able to hang himself on the night of July 31st last year while he was in a special suicide-watch cell. Last October, 17 prison staff were suspended over the incident.
Mr Bell's family said the report illustrated "his death could have easily been prevented", and Mr Goggins agreed with them. "There were significant failings at Maghaberry Prison and the death of Colin Bell should not have happened," he said.
For the night of July 31st last year, there is CCTV footage of Bell (34) - who was serving a life sentence for murder - attempting to take his own life on four occasions, the last one proving fatal, according to Ms McCabe's report.
Bell was committed to prison in March 2003 and his incarceration was "relatively uneventful" until March five years later, when he was found guilty of stealing a picture frame. He was moved from a lower-risk section of the prison to the general prison population. Between April and July, he self-harmed 15 times.
For his own safety, Bell, judged paranoid at the time, was moved to a suicide-watch "safer/ observation" cell. Over his last six days, he had "little contact with any person - his condition almost amounted to solitary confinement".
While Bell was dressed in anti-ligature clothing, his blanket was removed from him for his own protection. But, again from CCTV footage, there is evidence of him being cold in his cell on the last three days of his life.
On the last two nights, he used toilet-roll paper to try to keep his feet warm. There was no intervention from night custody staff while he was doing this, according to the report.
On the morning of July 31st, there is CCTV footage of Bell making ligatures in the morning, but no evidence of this being noted by prison staff. That night, over a period of 14 minutes, beginning at 10.57pm he could be seen holding a ligature and making three attempts to hang himself. Between his first and third attempt, he is viewed by CCTV walking around his cell with a ligature in his hands. He died after his fourth attempt at 11.41pm. It was a further 38 minutes before his body was discovered. That same night, Bell pressed the Samaritans call button in his cell 73 times. "Evidence suggests that around 63 of these presses resulted in an engaged tone. There is no evidence of any intervention in response to this level of attempted contact," the report said.
The Samaritans are carrying out their own investigation in respect of the calls. A spokeswoman said the number of calls did not tally with their records.
Among a catalogue of failings, Ms McCabe found specifically that evening staff did not carry out their 15-minute-interval checks as required. The officer responsible for viewing the CCTV footage of Bell's cell did not do so at the 15-minute intervals required.
This officer can be seen on CCTV "making and using a makeshift bed". Other prison officers were in this officer's supposedly secure and single unit, against prison regulations. They could be seen "chatting, smoking, watching television and using the computer".
Ms McCabe also noted some night custody staff had two and three jobs, which could have implications for their "capacity and fitness" to perform their duties.
She also said that some prisoners alleged that Bell asked for but was refused a "listener" the night he died - under a system whereby another prisoner trained by the Samaritans would come and sit with him in his cell. This could not be proved or disproved but there was evidence that "on occasions" he was refused such access.
Ms McCabe made 44 recommendations, the last of which says Maghaberry Prison governor Mr Longwell and deputy Mr Davis should be subjects of a "disciplinary investigation".
Mr Goggins, the prisons minister, apologised to Bell's family and pledged lessons would be learned from the report.
He said he was forming a review body which, among many prison reform responsibilities, would consider "whether any further disciplinary action is required against any member of staff, including those referred to in the ombudsman's report".
Among the body's members will be Kathleen O'Toole, head of the Garda Inspectorate.
Bell's family, which is to mount a case for damages, said the report was a "damning indictment of the entire prison system".
