Jack Mackenzie FAI

Ampersand counsel Douglas Ross KC, Isla Davie KC and Shane Dundas recently represented key parties in a significant Fatal Accident Inquiry into the tragic death of Jack McKenzie at HM Prison and Young Offenders Institution Polmont. The Inquiry was heard by Sheriff Collins KC who also issued the determination in the Inquiry into the deaths of Katie Allan and William Brown in January of this year following their deaths by suicide in Polmont.

Jack McKenzie, aged 20, tragically died by suicide in his cell at Polmont in September 2021. In his determination, Sheriff Collins noted several failures, particularly around ligature anchor points within Jack’s cell. His Lordship found that a reasonable precaution, which might realistically have resulted in the death being avoided, would have been for SPS to replace or modify the toilet cubicle door within Jack’s cell so that it was not readily capable of being used as a ligature anchor point. The Inquiry also identified that the lack of audit and subsequent removal of anchor points in Jack’s cell was a defect in the system of work which contributed to his death.

Several recommendations were made in relation to the auditing and modifying of cell structures, improving suicide risk assessment protocols, particularly for prisoners who suffer from drug abuse issues, and reintroducing certain cell safety checks.

You can read the full determination by Sheriff Collins KC here.

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FAI determination into deaths at HMPYOI Polmont issued

Sheriff Collins K.C. has issued his determination following a Fatal Accident Inquiry into the deaths by suicide of Katie Alan and William Brown at HM Prison and Young Offenders Institution Polmont (“Polmont”) in 2018. Ampersand Advocates’ Paul Reid K.C. acted on behalf of the Scottish Prison Service (“SPS”) and Isla Davie K.C. and Shane Dundas, Advocate acted on behalf of Forth Valley Health Board.

As both deaths occurred in custody, the Inquiry was mandatory in terms of s.2(4)(a) of the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016 (“the 2016 Act”). Whilst the deaths of Katie and William were not directly connected, the Lord Advocate determined that the deaths occurred in similar circumstances and a single inquiry was therefore held under s.14 of the 2016 Act. The FAI was heard at Falkirk Sheriff Court in a specially configured court, in which the inquiry into the M9 crash had also recently been heard.

The purpose of the Inquiry was to establish the circumstances of the deaths and consider what steps (if any) might be taken to prevent other deaths in similar circumstances in the future. Evidence was heard over a period of around four weeks.

In relation to Katie’s death, the Sheriff found that there were failures to identify, record and share information relevant to Katie’s risk in accordance with the suicide prevention scheme operated within Polmont. Notwithstanding that, it was not established, but for those failures, that Katie’s death might realistically have been avoided. The Sheriff found that Katie’s death was spontaneous and unpredictable and the evidence did not suggest that Katie should have been assessed as being at a risk of death by suicide prior to her death. However, the Sheriff found that it would have been a reasonable precaution to accommodate Katie in a cell that did not have a rectangular toilet cubicle door stop (which the Sheriff noted was a recognised potential ligature anchor point). That being so, the Sheriff found that removal of that potential ligature point would have been a reasonable precaution which, if taken, might realistically have avoided the death. In connection with that, the Sheriff held that a defect in the system of working which contributed to Katie’s death was that there was no system in place to regularly audit Katie’s cell for the presence of ligature anchor points or to remove or reduce such points as had been identified.

In relation to William’s death, the Sheriff found that there were several reasonable precautions which, if taken, might realistically have avoided his death. Those included: (i) keeping William on Talk to Me (“TTM”) (the suicide prevention strategy implemented in Polmont) observations rather than removing him therefrom the day after his admission; (ii) when further information was received about William’s background, reassessing William and putting him back onto the TTM strategy; and (iii) accommodating William in a cell which did not have a bunk bed in it, or otherwise removing the bunk bed. The Sheriff also found that there were several defects in the system of working. In addition to the same defect identified in relation to Katie’s death, defects which were identified as contributing to William’s death related to information sharing, actioning mental health referrals and the removal of persons from TTM in the absence of background information about them or their risk of suicide.

The Sheriff made several recommendations following the deaths of Katie and William. Those recommendations related to improving ligature prevention within Polmont, piloting the use of suicide prevention technology within Polmont, improving the system for acting on referrals made by the mental health team, improving the system of information sharing and recording between the courts, external agencies (including the families of those in custody), SPS and Forth Valley Health Board, and undertaking further training of staff. In addition, the Sheriff identified several matters which he recommended should be considered during the review of TTM which is already being undertaken by SPS (and, in connection with that, the Sheriff recommended that all Death in Prison Learning Audit Reviews should consider the safety of the physical environment when a prisoner dies by suicide).

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