Prison officers in Northern Ireland watched as a mentally ill prisoner blinded himself but did not intervene, a watchdog said.
Extreme and shocking self-harm was inflicted by Sean Lynch at the high-security Maghaberry Prison in Co Antrim in June 2014.
Warders did not step in during the hour-long ordeal because of security concerns and a failure to realise the seriousness of his injuries, according to Prisoner Ombudsman Tom McGonigle.
The report said: "It seems remarkable that the officers felt it was neither necessary not appropriate to enter his cell to prevent him from self-harming further.
"Their duty of care was trumped by security concerns that appear to have had little basis in reality."
Mr Lynch's mental health had deteriorated in the community and his behaviour in prison had become increasingly bizarre, the review said.
Although formal psychiatric assessment had been ordered by medics he was treated as a routine referral from court.
The Ombudsman said: "Much of Mr Lynch's main self-harm episode - he rendered himself blind and extended his groin injury - on 5th June was directly observed by prison officers.
"Although they complied with a strict interpretation of governor's orders which require intervention if a situation is life-threatening, Mr Lynch did not meet the definition."
He had self harmed on 20 occasions on 5 June. Prison officers watched for more than a quarter of the ordeal, which lasted longer than an hour.
The report said: "It seems remarkable that several experienced Northern Ireland Prison Service 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."
The main reason they suggested for the delay was that they did not realise the seriousness of his injuries.
They also believed four staff would be unable to manage him, and that there could be a risk to prison security if he were to obtain the keys they carried.
The Ombudsman said officers complied with a strict interpretation of the Maghaberry Governor's orders, which required intervention if a situation was life-threatening. Their response contradicted the self-harm policy.
Mr Lynch was supposed to receive six mental health reviews but only one took place and it took two weeks for him to see a psychiatrist.
The report said: "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."
The review noted Mr Lynch faked symptoms on some occasions and this led certain prison officers to believe he was being manipulative to secure removal to a different location.
"This belief, which was also partly caused by insufficient awareness of his mental illness, impacted negatively upon his management and care."
The prison authorities noted Mr Lynch's condition was beyond anything officers could cope with and said it was important lessons were learned.