Failing to discipline prison officers after an inmate took his own life “condoned” bad practice at a young offenders’ institution, the Scottish Prison Service has been warned by a sheriff.
Jack McKenzie, 20, died in his cell at Polmont YOI in September 2021, nine months after being remanded on rape and sexual assault charges, which he denied.
Mr McKenzie was pronounced dead in his cell at 7.57am on September 3, after taking his own life which was deemed “unpredictable” in a fatal accident inquiry (FAI) determination by Sheriff Simon Collins, after hearing evidence at Falkirk Sheriff Court.
Mr McKenzie had been confined to his cell following an “aggressive” outburst attributed to drugs on September 1.
His death could have occurred between 3am and 7.36am, the inquiry found, however, two prison officers tasked with a “hatch check” just after 6.30am did not do so sufficiently, and a total of seven recommendations were issued to Scottish Prison Service (SPS) regarding improvements.
Sheriff Collins said in his determination “poor practice must be investigated and sanctioned, not ignored and therefore – apparently – condoned”.
It added: “The purpose of imposing a sanction is not to criticise prison officers for the sake of it, but to seek to drive up standards in the hope – in the present context – of preventing the deaths of further young prisoners by suicide.”
A six-month deadline was set for SPS to reduce “abusive and bullying verbal behaviour, drug dealing, and to respond to physical disturbances” during the night, in the sheriff’s determination.
Mr McKenzie was described as a “chronic drug user” who had been remanded four times in three years in Polmont YOI, however, his death was described as “impulsive” and a report called for improvements to cell environments.
Sheriff Collins, who presided over the Katie Allan and William Brown FAI, which also investigated Polmont, said 10 young prisoners died by suicide there between 2010 and 2023, while more than 120 prisoners died by suicide in Scottish prisons between 2011 and July 2024.
A total of seven recommendations were made, and the report said: “Jack’s death was spontaneous, unpredicted and unpredictable. But it is well known that prisoner suicides can be so.
“Accordingly prisoners should, insofar as reasonably possible, be detained in environments which are safe, in the sense of minimising the risk of such suicides.”
The report said an audit had been done of potential suicide risks in equivalent cells and using the Manchester Tool Kit (MTK), Mr McKenzie’s cell would have “indicated the highest level of risk”.
It said: “If a young, vulnerable prisoner was accommodated, without regular observation, the resulting overall MTK scoring for the cell would have indicated the highest level of risk, calling for remediation.”
The sheriff wrote it “would have been a reasonable precaution for the Scottish Prison Service prior to September 2021, to have removed and replaced the toilet cubicle door in Jack’s cell, or to have modified it, such that it was not readily capable of being used… without significant ingenuity or adaptation”.
Mr McKenzie was perceived by staff as “jovial, funny, likeable and talkative” but on drugs could be “aggressive, agitated and anti-authority” and traded substances. However, he had never been assessed as suicidal, the report added.On September 1, Mr McKenzie smashed two phones and was restrained and confined to his cell due to becoming “non-compliant” and intoxicated – using an order which would have expired on September 4 just after 3pm.
The report said: “There was simply nothing to indicate, prior to September 3 2021, that Jack had any thoughts or intention of dying by suicide”.
Accounts from neighbouring cellmates suggested “that Jack was still alive at around 3am to 4am” on September 3, the report said.
At 6.37am on September 3, two prison officers failed to carry out a hatch check at Mr McKenzie’s cell to ensure he was safe and failed to take steps to ascertain his whereabouts, and did not log concerns on a handover, it added.
A recommendation said: “A sanction should have been imposed on both officers and/or corrective training required of them.”
Governor Gerry Michie did not issue any “disciplinary action, reprimand, warning or sanction” and neither officer was “offered, nor required, to undertake additional training “- which was branded “unacceptable” in the report.
The report said: “The absence of any disciplinary action, given the seriousness of the breach, and the possible seriousness of the consequences of it, is incongruous and unacceptable.
“I do not accept, as SPS submitted, that this was within the range of reasonable responses open to governor Michie.
“Rather, it was a response which sends a message to prison officers that they will not be held to account for a failure to ‘do the basics well’, and a message to the public that the first response of SPS to poor staff practice in the context of the death of a prisoner is to close ranks and protect its own.”
Procurator fiscal Andy Shanks said: “The sheriff’s determination, which makes significant recommendations in relation to reduction and prevention and the checking of cells, is extensive and detailed.
“The FAI followed a thorough and comprehensive investigation by the procurator fiscal who ensured that the full facts of Jack’s death were presented in evidence. My thoughts remain with Jack’s loved ones.”
An SPS 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.”
Justice secretary Angela Constance said: “I wish to express my deepest condolences to the family of Jack McKenzie, I am deeply sorry about his death.
“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 underway to put in place the necessary reforms to make our prisons safe and rehabilitative.
“I thank Sheriff Collins for his detailed determination which has highlighted a number of reasonable precautions that should have been taken and systemic failures that must be addressed to help prevent other deaths in custody.
“His recommendations will be given very careful and detailed consideration and responded to formally by July 11.
“Delivering lasting change must be underpinned by accountability and transparency at every stage which is why I have established a ministerial accountability board to provide oversight and drive progress.”
