A report into Derry man Sean Lynch, who blinded himself while prison officers watched, has highlighted one of the most disturbing cases to come out of Maghaberry Prison in recent times.
Mr Lynch found himself on remand in the high-security jail in 2014 for breaching bail conditions.
Although formal psychiatric assessment had been ordered by medical staff, he was treated as a routine referral from court.
However, this man's mental health deteriorated significantly during his time in prison and he engaged in numerous episodes of self harm.
The most serious incident took place on June 5 when Mr Lynch, whose behaviour had become increasingly bizarre, gouged out his own eyes while in his cell.
According to a report by the Prisoner Ombudsman Tom McGonigle, this horrific ordeal lasted longer than an hour and for part of that time his self-mutilation was witnessed by several prison officers who did not intervene.
Many people will find that fact absolutely shocking.
The main reason put forward for the delay in intervening was that warders did not realise the seriousness of his injuries and also believed that four staff would be unable to manage him. Furthermore, there was said to be a risk to security if he obtained their keys.
Mr McGonigle said: ``Their duty of care was trumped by security concerns that appear to have had little basis in fact.''
A key issue arising from this distressing case is how the criminal justice system, and our prisons, care for prisoners with severe mental health problems.
Concerns over the wellbeing of vulnerable people in our jails have been raised time and again.
In this instance, Mr Lynch was supposed to get six mental health reviews but only one took place and it took two weeks for him to see a psychiatrist.
This prisoner needed urgent, specialist medical attention and it is questionable whether Maghaberry was the appropriate place for this vulnerable person.
Justice minister Claire Sugden has pointed to an independent assessment in the Ombudsman's report which said Mr Lynch's condition was beyond anything that prison officers could cope with.
The South Eastern Health and Social Care Trust, which is responsible for healthcare in prisons, commissioned a review which highlighted that ``dealing with drug misuse and associated mental health issues within a custodial setting is very difficult.''
As we know, our prison system has to deal with people who have a range of often complex mental health issues.
Today's report highlights a horrendous case which should lead to changes that ensure a prisoner at risk of suicide or self harm receives the care they need.
