THE death of a 28-year-old prisoner found unresponsive in his cell in Maghaberry Prison in 2018 "could not have been predicted", the Prisoner Ombudsman has found.
Emmett Cassidy died in hospital on December 11 2018, four days after he was found in his cell.
An inquest into his death is still pending.
A report by ombudsman Dr Lesley Carroll found that Mr Cassidy had a history of self-harm and struggled with drug addiction.
She found that the Prison Service and prison healthcare "had followed the processes and procedures in place" but "lacked a means of connecting a series of individual incidents which could have led to a better understanding and response to Mr Cassidy's specific needs".
The Independent Clinical Reviewer Professor Jenny Shaw concluded that Mr Cassidy's death could not have been predicted with any certainty.
Although there were missed opportunities in his care, she said these would not have prevented his death.
Dr Carroll again welcomed the recommendations made an RQIA report on vulnerable prisoners, which was published in October,
"It is imperative that this work is completed without delay and that services involved remain open to further improvement to ensure the safety of those who are in custody," she said.
A spokesman for the Prison Service extended its sympathies to Mr Cassidy's family.
"While there are no recommendations in the Prisoner Ombudsman’s report for the Prison Service (NIPS), there are important findings," he said.
"NIPS will continue to work closely with the South Eastern Health and Social Care Trust to support vulnerable people in our care.
"This includes ongoing work to address the recommendations in the recent RQIA Report."