Prison officers who watched as a mentally ill prisoner blinded himself were not sufficiently trained to deal with such a severe case, the the North's Justice Minister has told the Northern Ireland Assembly.
Shocking levels of self-harm were inflicted by Sean Lynch at high-security Maghaberry Prison in Co Antrim in June 2014.
A report published by Prisoner Ombudsman Tom McGonigle earlier this month 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.
Minister Claire Sugden said she did not shy away from the report's "damning" findings.
She told Assembly question time that the issue of staff training needed to be looked at.
"This was an exceptional mental health case," she said. "To be honest, our officers were not equipped to deal with that exceptional case. We need to look at how we can better equip officers to deal with those sorts of cases. Severe lessons have been learned from that, and I will ensure that we do."
The minister said she had not met Mr Lynch's family but was happy to do so.
The ombudsman found that Mr Lynch's mental health had deteriorated in the community and his behaviour in prison had continued to worsen.
Although formal psychiatric assessment had been ordered by medics he was treated as a routine referral from court.