Young prisoner's death could have been prevented, sheriff rules
BBCA 20-year-old's death in prison could have been prevented if reasonable precautions had been taken, a sheriff has determined.
Jack McKenzie took his own life in Polmont Young Offenders Institution in September 2021.
The inquiry found there was a realistic possibility his death could have been avoided if the Scottish Prison Service (SPS) had replaced a door in his cell.
The SPS and the Scottish government have apologised to his family for his death and committed to improving the conditions in prisons.
Following a fatal accident inquiry (FAI) last year, seven recommendations have been made in papers released by Sheriff Simon Collins.
One of them is that two prison officers should have been disciplined for failure to carry out an adequate hatch check the morning Mr McKenzie died.
Mr McKenzie died three years after two other young people took their own lives in the same jail.
Katie Allan, 21, and 16-year-old William Brown - also known as William Lindsay - died in the institution in 2018.
Their joint FAI heard that both inmates were vulnerable while at the facility near Falkirk and Sheriff Collins - who presided over both inquiries - made 25 recommendations including for the prison service to make definite and practical steps to make cells safer.
Mr McKenzie was on remand in Polmont accused of rape and sexual assault charges - which he denied.
On 1 September 2021 he had been due to attend court and thought there was a chance he could be released.
During the day he became agitated and was assessed as being under the influence of an illegal substance.
He was placed on observations and put into isolation where he was only released from his cell for about 20 minutes in a 24-hour period.
The inquiry heard the drug etizolam had been passed into his cell in the early hours of 3 September and he had been shouting from the windows.
SPSA prison officer should have checked he was in his cell at 06:30.
The officer looked through the hatch, did not see him but took no further action.
At the next check, at about 07:30, the 20-year-old was found dead.
He had taken his own life just hours after taking the etizolam.
Sheriff Collins said it was well known within the SPS for at least three years prior to Jack's death that a door in his cell presented an obvious suicide risk.
He said doing nothing was not a reasonable option.
As with his previous determination, Sheriff Collins recommended that steps be taken to make cells safer.
He also recommended that:
- Visual hatch checks should be reintroduced about an hour before the end of the night shift to ensure that all young prisoners are safe and well at that time.
- There ought to be a review of active patrolling at night to better reduce abusive and bullying behaviour and drug dealing.
- There should be better training and risk assessments for prisoners where drug use is an issue.
The Scottish Prison Service previously accepted all 25 recommendations made by Sheriff Collins following Ms Allan and Mr Brown's deaths.
Linda Allan, mother of Katie Allan and an honorary professor at the University of Glasgow, told BBC Scotland News: "Our deepest condolences go to Jack's family and friends and our thoughts are with them as they receive this determination.
"It is devastating to lose a child, a nephew, a brother, it is even more so to discover that state negligence contributed to their death.
"It is irrefutable that Polmont is not fit for purpose and it certainly is not the 'leading edge institution' it was claimed to be.
"It is dangerous and unsafe."
She said it had taken the deaths of numerous young people, including her daughter, and years of campaigning at great personal cost to expose the toxic culture in the facility.
She added: "We sincerely hope that the recent parliamentary commitments given are fulfilled at pace. Our gratitude is once again given to Sheriff Collins for his thorough and compassionate determination."
A Scottish Prison Service spokesman 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."
The justice secretary confirmed the Scottish government would formally respond to the sheriff's report by 11 July.
Ms Constance said: "Deaths from suicide in custody are as tragic as they are preventable, and Jack's death should not have happened whilst he was in the care of the state.
"I have been clear that there needs to be systemic change and action at pace to ensure we prevent avoidable deaths in custody.
"Work is well under way to put in place the necessary reforms to make our prisons safe and rehabilitative."