Prison chiefs have been censured over the death of a father of eight found hanging in his cell, the Health and Safety Executive (HSE) said today.
Danny Rooney, who was known as John Hughes, was found dead at Bullingdon Prison in Oxfordshire while awaiting sentencing for burglary on September 26 2006.
He was put in a so-called "safer cell" after being found with a noose around his neck, but the cell had been modified to include shower rails offering ligature points, the HSE said.
Rooney, 38, was in the cell for just 40 minutes, during which he was checked by staff three times, before he was found hanging with a ligature fixed to the shower rail support bracket.
The National Offender Management Service (Noms) was criticised after the HSE found the brackets should have been attached to the wall with weaker fixings that would not have supported the ligature used by Rooney.
But it has not been possible to prove "when the shower rail was installed, who installed it, who authorised its installation or who checked it had been fitted in an appropriate way in a 'safer cell"', the HSE said.
Rooney, from Hollow Way in Oxford, was part of the travelling community and had been on remand for burglary for 15 days when he was found hanging the day before his 39th birthday.
His widow Ann said: "It has been a very hard fight from the start to find out what happened to Danny and for the prison to accept that they did wrong.
"I still don't think we have the full picture but I hope this case at least stops other families from going through what we have."
Carolynn Gallwey, of the family's solicitors Bhatt Murphy, welcomed the censure but added: "This case also emphasises the need for timely and unflinching investigations into custodial deaths, which are capable of earning the trust and confidence of the bereaved family.
"It should not be left to them to shoulder the burden of trying to find out what happened to their loved one."
Heather Bryant, director of the HSE's southern division, said: "This was an unnecessary tragedy and shows that all refurbishment programmes need to be adequately controlled.
"The standard in this cell was far below what is appropriate for those vulnerable prisoners in a safer cell."
Matthew Lee, the HSE's investigating inspector, added that Noms "should have had a more robust system for ensuring the risk was adequately controlled at HMP Bullingdon".
"Staff on duty at the prison at the time of the death were clearly under the impression that they had placed Mr Rooney in a safer cell which, so far as was possible, was ligature free," he said.
A Noms spokeswoman said: "The death of Mr Rooney was a tragedy, our sympathies are with his family and friends.
"Since Mr Rooney's death there have been significant developments in the Noms policy for the care of prisoners who are at risk of suicide and/or self-harm, including guidance on the use of safer cells.
"Work has also been undertaken to raise awareness of the importance of maintaining the integrity of safer cells."
She went on: "Noms strives to learn from all deaths and cascade that learning across the prison estate.
"In particular, Noms learns from both the Prisons and Probation Ombudsman report and from the coroner's inquest.
"We will fully consider the censure issued by HSE and ensure that the issues raised by them have been addressed."