A watchdog tasked with investigating a recent of spate of suicides and self-harm incidents inside Northern Ireland prisons has questioned the ongoing delay in reviewing a key care and treatment policy.
Prisoner Ombudsman Tom McGonigle said there was a "moral imperative" on the justice and health authorities to complete the redrafting of the prison suicide and self-harm prevention policy.
The recommendation to review the policy within nine months was made in an inspection report in October 2014.
Mr McGonigle, who was giving evidence to the Assembly's health committee, expressed concern it was still not finished two years later.
"I don't get why things can't be done within two years - it doesn't make sense to me," he said.
"As a moral imperative, if a recommendation is made and not accepted then that's fine.
"If a recommendation is made and accepted by, in this case the two parties involved - the trust (South Eastern Health and Social Care Trust) and Prison Service, I think there is a moral imperative that they should deliver that.
"That recommendation said that the revamped suicide and self-harm policy should be in place within nine months. We are two years on and it hasn't happened - I don't get that."
The recommendation was made in a joint inspection report by Criminal Justice Inspection NI and the Regulation and Quality Improvement Authority (RQIA).
Five people have died in custody in the last 12 months - four of the deaths were suspected suicides.
On Monday, Justice Minister Claire Sugden said she and Health Minister Michelle O'Neill were launching a review into vulnerable prisoners in the wake of the incidents.
Ms Sugden also told the Assembly that the new suicide and self-harm prevention policy was "still in development".
Mr McGonigle was briefing committee members on two recent investigations into care failings in respect of a fatal overdose and a serious self-harm incident.
Prisoner Sean Lynch blinded himself and inflicted other serious injuries during a sustained period of self-harming inside Maghaberry Prison in June 2014.
Mr McGonigle's report found that warders did not step in quickly enough during the hour-long ordeal because of security concerns and a failure to realise the seriousness of his injuries.
He also discussed the case of Patrick Kelly, who died in February last year after overdosing on prescribed medication he stockpiled inside Maghaberry when safeguarding measures were lifted.
The ombudsman said several opportunities to help Mr Kelly had been missed while he was on remand.
He said prison officers and nurses overlooked crucial medical documents and failed to recognise that Mr Kelly was at high risk of self-harm.