Sheriff makes 7 recommendations following FAI in to the death of Jack McKenzie

Jack McKenzie died at HM Prison and Young Offenders Institution at Polmont. Now a sheriff has found that there were reasonable precautions by which the death might realistically have been avoided.

This morning, the Scottish Courts and Tribunal Service released Sheriff Simon Collins KC's full Fatal Accident Inquiry report into the death of Jack McKenzie who died at HMYOI Polmont in the early hours of September 3, 2021.

The full determination can be downloaded at the end of this article.

Sheriff Collins found that there were reasonable precautions by which Jack's death might realistically have been avoided.

The report contains seven recommendations which, if implemented, might prevent deaths in similar circumstances in the future.

Jack, 20, died sometime between 3am and 7.36am on September 3, 2021 in his cell in Monro Hall at the young offenders institution.

The cause of death was hanging and the sheriff concluded Jack's death was self-inflicted and not the result of an accident. 

The inquiry determined that a prison officer, David Nelson, failed to carry out a hatch check at Jack's cell to the standard which could have determined he was safe and well and that he should have been disciplined for this failure.

Officer Zaira Afzal, on duty with Officer Nelson, was jointly responsible for the hatch check and should also have been disinclined and a sanction or corrective training for both should have also been implemented.

Finally, Sheriff Collins determined that neither SPS Talk To Me suicide prevention policy (TTM) nor its Management of an Offender at Risk from any Substance policy (MORS) placed any requirement on Nurse Elizabeth Forrester to carry out, and record, a suicide risk assessment prior to removing Jack from MORS at 1430 hours on 2 September 2021, hours before his death.

The recommendations, which can be read in full below, focus on cell safety at Polmont, suicide risk assessments, TTM guidance in cases of young prisoners with history of drug abuse, introduction of a changed visual hatch check protocol and active patrolling.

Scottish Prison Service Response

A Scottish Prison Service spokesperson said: “We would like to offer our sincere condolences and apologies to the family of Jack McKenzie for his sad death and the failings identified in this report.

“We are grateful to Sheriff Collins for his recommendations, which we will fully consider as we continue to deliver systemic change, at pace, in a way which keeps young people in our care safe, during one of the most challenging and vulnerable periods of their lives."

Sheriff Collins seven recommendations following death of Jack McKenzie

• 1) SPS should take steps to make standard cells at Polmont safer by identifying and removing, as far as reasonably practicable, ligature anchor points present in such cells. In that regard it should:
  • a. Develop a standardised toolkit for auditing cells for the presence of ligature anchor points. This toolkit should, in particular, (i) identify both obvious and potential ligature anchor points; (ii) specify whether such points are inherent to the design of fixtures or fittings within the cell, or due to modification of, or damage to, such fixtures and fittings; (iii) provide a system of grading the level of risk in relation to each identified ligature anchor point (for example, by reference to the ease/level of ingenuity required to use it for self-ligature), and so provide a system of grading the level of ligature anchor point risk in relation to the cell as a whole;
  • b. Use the foregoing toolkit to conduct an audit of potential anchor ligature points within all standard cells. This should result in the production of a report detailing all obvious and potential ligature anchor points within each cell, identifying whether they are inherent to the fixtures and fittings within the cell or are due to modification or disrepair, and provide a grading of the risk for each identified ligature anchor point and for the cell as a whole;
  • c. In the light of the foregoing audit:
    • i. As regards any ligature anchor points arising from damage to or modification of fixtures or fittings, (a) repair or replace same so as to remove or at least reduce the risk of ligature arising therefrom as soon as practicable; and thereafter (b) institute a
      policy of regular ongoing cell audit using the said toolkit so as to promptly identify and repair or replace any further damage or modifications which have created further ligature anchor points;
    • ii. As regards any ligature anchor points arising from the inherent nature of fixtures or fittings, (a) develop and publish a plan for their phased removal, replacement or modification, again so as to remove or at least reduce the risk of ligature arising therefrom; (b) specify a timeframe over which this plan is to be implemented having due regard to available resources; (c) commence implementation, for example, beginning with removal, replacement or modification of those fixtures and
      fittings graded as presenting the highest level of risk pursuant to the said toolkit; and (d) publish annual reports of progress in implementation of the said plan;
  • d. Ensure that proposed fittings and fixtures in any new build or refurbished cells are audited using the said toolkit at the planning stage, and that any fittings or fixtures graded as presenting an inherent and significant risk of being used as ligature anchor points are not included within such cells when built or refurbished.
• 2) All cell toilet cubicle doors of the type identified in the book of
  photographs which forms Crown Production 16 (photographs 22, 24, 30 - 35), and which are of the same or equivalent design as the door used as a ligature anchor point by Jack, should be removed from standard cells occupied by young prisoners in Polmont and either replaced with doors of an anti-ligature design, or modified so as to materially reduce the ligature anchor point risk which they present.
• 3) Where a prisoner has died by suicide, the DIPLAR process must consider, and if so advised make recommendations, in relation to the safety of their physical environment within Polmont and the means by which they were able to complete suicide. Where suicide has been by self-ligature, the DIPLAR process must consider the ligature anchor point risk of the cell or other place in which the death by suicide took place, and the nature and availability of the
  item used as a ligature.
• 4) When a chronic or habitually drug using prisoner is removed from MORS they should be the subject of a suicide risk assessment under TTM. That assessment should involve a review of any previous TTM and MORS records and follow a standardised, approved process. The outcome of the assessment should be recorded in a prescribed form, and stored in an accessible format.
  TTM and MORS should be amended accordingly.
• 5) TTM Guidance and training materials should be amended to make express reference to, and provide greater emphasis on, the heightened risk of suicide by a young prisoner who abuses drugs whilst in Polmont. In particular these materials should be amended so as to direct staff of the need to take account of chronic or habitual drug use by a young prisoner in assessment of their suicide risk.
• 6) A visual hatch check, around one hour before the end of the night shift, should be reintroduced at Polmont, in order to seek to ensure that all young prisoners are safe and well within their cells at this time.
• 7) SPS should review the instructions given to staff at Polmont regarding active patrolling of residential halls during patrol and  night shifts. In the context of this review SPS should seek to identify ways to better reduce, at night, abusive and bullying verbal behaviour, drug dealing, and to respond to physical disturbances by prisoners within their cells. This review should also consider the adequacy of present staffing levels for this purpose. It should be completed within 6 months of the date of this determination, and a written report made to Scottish Ministers.