THE parents of a man found dead in a prison cell have said no other family should have to experience their "sadness and pain".
David O'Driscoll (30) died by suicide on August 12 2016 at Maghaberry Prison in Co Antrim. He was found in a cell in the jail's committal house seven hours after arriving at the unit.
A few hours before his death, Mr O'Driscoll's mother had phoned the prison to raise concerns about her son's welfare after he had called her home and threatened to kill himself, a report by the Interim Prisoner Ombudsman has found.
After making inquiries, the day manager on duty returned Mrs O'Driscoll's telephone call and reassured her that her son was fine.
Mr O'Driscoll, a father of two, died later that evening.
In a statement issued through their solicitor, Mr O'Driscoll's parents Mary and Michael said the prison authorities knew he was a vulnerable adult with a history of severe depression.
"There appears to be a complete lack of systems and procedures to ensure against the tragedy of my son taking his life and more importantly a blatant lack of the proper training and procedures to deal with the tragedy that we have suffered," they said.
"What we seek to happen is to ensure that no other mother, father, brother, sister, son or daughter experiences the sadness and the pain that has been inflicted upon us by the avoidable death of David."
The ombudsman's investigation found no one had spoken directly to Mr O'Driscoll about the call he had made to his mother's home.
The reassurance given to Mrs O'Driscoll was based on a conversation the prisoner had with an officer on the committal landing earlier that day.
Interim Prisoner Ombudsman for Northern Ireland, Brendan McGuigan, said: "It is particularly distressing in this case that after being reassured by the prison about her son's wellbeing, Mrs O'Driscoll was later told that he had died.
"This case highlights important lessons about how information provided from relatives of those in prison should be addressed.
"I wish to impress on prison staff the importance of staff handovers and record keeping which in this case fell short of the standards required.
"It is clear that some aspects of Mrs O'Driscoll's telephone call could have been managed better and there was no evidence that a number of measures the manager asked to be put in place were completed.
"The investigation identified an inadequate handover from NIPS (Northern Ireland Prison Service) day staff to night staff and poor record keeping, which regrettably is a recurrent finding in Prisoner Ombudsman death in custody investigations."