The recommendation is one of seven included in Dr Lesley Carroll’s report into the death of 27-year-old Paul Johnston in Magilligan Prison in 2017.

Mr Johnston’s death was drug-related and it did not appear that he intended to take his own life, she found.

The prisoner ombudsman said the key learning point for the Northern Ireland Prison Service and the South Eastern Health and Social Care Trust is that people with vulnerabilities need to be more effectively identified in order that they may be kept safe while in custody.

She made a number of recommendations aimed at helping to prevent a death in future, including consideration of what is taken into account when people transfer from one prison to another; the effectiveness of substance withdrawal monitoring; the response when some-one stops taking their medication; and the adoption of technology to reduce the supply of drugs coming into prison.

Dr Carroll said: “I am concerned about the devastating impact of substance misuse and poor mental health which resulted in Paul’s untimely death. Sadly, we know this is not an issue confined to those who live and work within prisons.

“This problem requires a broad response taking the whole life of communities into account and targeted at both prevention, by addressing the root causes of behaviours that can result in people losing their lives in these circumstances, and also response so that people can access effective services when they most need them.

“Prisons should play their part in an overarching strategy but the challenge is systemic and society-wide.”