Officers at the troubled Maghaberry Prison looked on for over twenty minutes as a disturbed prisoner gouged his eyes out and mutilated his genitals.

The incident has now given rise to a damning report by Tom Mcgonigle, Prisoner Ombudsman for Northern Ireland, in which he makes 63 recommendations on how the Prison Service and South Eastern Health Trust can improve.

The report finds that “The self-harm that Sean Lynch inflicted in Maghaberry Prison between 2nd and 5th June 2014 was extreme and shocking.”

It notes that ”A detailed Forensic Medical Officer’s assessment was prepared for the court which remanded Mr Lynch in custody on 22 nd April 2014 which suggested that formal psychiatric assessment was an ‘absolute necessity.’”

Yet, Mr Lynch was treated as a routine referral at Maghaberry. He was meant to have six mental health reviews pending the psychiatric assessment, but only one took place. It took two weeks for Mr Lynch to see a psychiatrist.

The report continues: “Numerous people from the NIPS and the SEHSCTwere involved, but nobody took overall responsibility for managing him, either as a patient or as a vulnerable prisoner. Events moved faster than the official reaction, and his increasingly bizarre and violent crises were met by short-term responses which included several moves of location and placements in observation cells with anti-ligature clothing.

“His final location, Quoile House, was unsuitable for managing someone who was so disturbed. A contemporary, independent assessment by a priest is informative: he said on 1st June ‘His condition is beyond anything the officers can cope with.’”

In a damning paragraph, the report reveals: “Mr Lynch’s main self-harm episode on 5th June lasted for 67 minutes. During that period he was directly observed by prison officers for 27% of the time.

“He self-harmed on 20 separate occasions, each lasting an average of 26 seconds. During this time he damaged both eyes to the extent he rendered himself blind and extended his groin injury.

It seems remarkable that several experienced NIPS officers, including a Senior Officer, all felt it was neither necessary nor appropriate to enter his cell to prevent Mr Lynch from self-harming further.”

Prison Service Director General Sue McAllister said: ” I hope that the recommendations to be taken forward will provide some comfort to Mr. Lynch and his family that lessons have been learned from this tragic case”.

The full report can be downloaded here: http://www.niprisonerombudsman.gov.uk/publications/dic/WEB_VERSION_-_Prisoner_Ombudsmans_FINAL_Investigation_Report_-_Sean_Lynch.pdf