Prison officers restrained a suicidal inmate hours before he was found hanged in his cell. Against official policy, staff at Brixton Prison then failed to ensure Kazaar McKenzie was checked over by healthcare staff, who could have taken action.

The 29-year-old was restrained by officers after kicking his cell door open and trying to force his way past them on a landing on June 5. He was unhappy about having to share his cell with another prisoner.

The previous day, an officer noted that that Mr Mckenzie had said he could no longer cope. He was subsequently put on suicide watch, but officers failed to tell healthcare staff this or ensure a risk assessment was completed within 24 hours.

On June 5, Mr McKenzie, who had a history of mental health problems, refused lunch and dinner and blocked his cell's observation panel so staff couldn't see him. When officers found him hanged around 7:15pm the same day, they delayed declaring an emergency for five minutes.

The failings were revealed in a Prisons and Probation Ombudsman report into Mr McKenzie's death at the medium-security prison in South London. The ombudsman made several recommendations in light of the investigation, including that risk assessments are completed on-time, staff use emergency codes appropriately and prisoners are examined by a doctor or nurse following use of force.

The report, published on July 21, reads: "We are concerned that when Mr McKenzie was restrained on 5 June, he was not seen by a member [of] healthcare staff. Although it is clear from the post-mortem report that Mr McKenzie did not sustain any significant injuries during the restraint, the extent of his emotional distress may have been apparent if he had been seen by healthcare staff.

"This may, therefore, have been a missed opportunity to identify his level of risk and put appropriate support in place."

Mr McKenzie arrived at HMP Brixton in January 2019 after requesting a transfer from HMP Wandsworth. He was serving a 22-month sentence after being convicted of drug offences in August 2018.

Mr McKenzie had tried to kill himself three times while outside of prison. During the first part of his sentence at Wandsworth in December 2018, he was found suffering from self-harm injuries in his cell. He told officers he was hearing voices telling him to kill himself.

Criticising staff's response at HMP Brixton the following year, the report continues: "No one notified the healthcare team that Mr McKenzie was subject to ACCT [suicide and self harm] monitoring. What Mr McKenzie told an SO [supervising officer] on 4 June about his guilt over his previous behaviour is very similar to what he said when he self-harmed in December 2018.

"On the previous occasion he had been referred to a psychiatrist who diagnosed a brief psychotic episode and prescribed medication. If healthcare had been told that an ACCT had been opened on 4 June and participated in the first ACCT review, it is possible that Mr McKenzie's medical records might have been reviewed in detail and the similarity of his presentation with that of December 2018 might have been picked up – although we cannot be certain of this."

The report also revealed Mr McKenzie alleged to a friend that he was being bullied by officers at the prison in the weeks before his death. He said they were talking loudly outside his cell door to provoke him and turning off his power in texts sent on May 30. The ombudsman said while other evidence suggested he had a good relationship with staff, it could not "say categorically" that Mr McKenzie wasn't being bullied by staff.

A Prison Service spokesperson said: "Our thoughts remain with Mr McKenzie's family and friends. We have implemented all of the Ombudsman's recommendations and are investing £37m over the next three years to make prisons safer, with prison helplines, ligature-resistant cells and further training for staff."