Form 6.2

RESPONSE

SHERIFFDOM OF NOTH STRATHCLYDE AT KILMARNOCK

Court ref: KIL-B178-24

DETERMINATION OF SHERIFF N. K. PATRICK

UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016

in the inquiry into the deaths of

                                                            BRENDAN REILLY             

To the Scottish Courts and Tribunals Service

1. HMP Kilmarnock was operated by Serco Ltd at the time of Mr Reilly’s death, thereafter it transitioned to operation under the Scottish Prison Service (SPS) on 17 March 2024. Although, the recommendations under section 26(1)(b), listed below were addressed to Serco Ltd, as SPS are now responsible for the operation of HMP Kilmarnock, we respond as follows.

2. Recommendation 1 – That HMP Kilmarnock review the arrangements for ensuring and monitoring compliance with the roll count policies and procedures.

3. Response 1 – SPS have incorporated into Prisoner Officers annual C&R refresher training course, a section of training on the necessity of adhering to SPS locking and unlocking procedures to ensure that appropriate steps are taken by Prison Officers to see the face of, and get a verbal response from all prisoners during these procedures. HMP Kilmarnock have re-issued their local Standard Operating Procedures in relation to locking and unlocking number counts to all operational staff and emphasised the necessity to staff the importance of adhering to SPS locking and unlocking procedures. Further, HMP Kilmarnock has also incorporated this into residential staff daily briefings and information relating to locking and unlocking number counts must now also be included in the daily handover report with managers and senior managers. Compliance with locking and unlocking number counts are routinely observed by senior managers to ensure adherence to the SPS locking and unlocking procedures.

4. Recommendation 2 - That HMP Kilmarnock should comply with the recommendation made by the Significant Adverse Event Review, namely to implement an effective policy concerning communication for requesting an ambulance in emergency situations.

5. Response 2 – HMP Kilmarnock’s contact details were re-issued by NHS colleagues to emergency services on 21 May 2025, including the Scottish Ambulance Service (SAS). This communication provided SAS with HMP Kilmarnock’s direct dial phone number for their Electronic Control Room (ECR) which is manned 24 hours a day, 7 days per week, to be used in emergency situations.

The recommendations and learning from this Determination will be shared across the SPS to support wider learning and compliance.