Form 6.2

RESPONSE

SHERIFFDOM OF TAYSIDE, CENTRAL AND FIFE at FALKIRK

Court ref: FAL-B30-24

DETERMINATION OF SHERIFF S G COLLINS KC

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

in the inquiry into the death of

JACK MCKENZIE

                                                           

To the Scottish Courts and Tribunals Service

 

1. The Scottish Ministers, of which the Scottish Prison Service (SPS) is an executive agency, being the body to whom recommendations under section 26(1)(b) were addressed, do respond as follows.

 

2. To reflect the Sheriff’s recommendations, and for clarity, the response refers to both Scottish Ministers and SPS.

 

3. SPS extends its sincere apologies to the family of Jack McKenzie for his death while in SPS care.  The findings of this FAI and others have made clear that immediate action and systemic change needs to occur, driven by a commitment to learning from the deaths of young people in our custody.

 

4. The Determination has highlighted key areas requiring improvement and has reinforced the importance of work already underway to strengthen safeguards and support systems. Under the governance of a dedicated Taskforce, this work includes ongoing significant revisions to our suicide prevention strategy through the independent review of Talk to Me, reviewing our items in use list for young people at HMP & YOI Polmont and the introduction of a mandatory 72-hour observation period for all young people entering custody. These steps are part of a broader effort to create a safer, more responsive environment for those in our care. SPS is committed to learning from this tragedy and ensuring that the lessons lead to lasting, meaningful change. 

 

5. The majority of the recommendations are accepted in full, and we are committed to their implementation. Recommendation 6, however, requires further exploration. In addition, several of the recommendations arising from this FAI are the same as those previously set out in Sheriff Collins’ Determination following the Inquiry into the deaths of Katie Allan and William Lindsay (Brown), to which SPS has provided a detailed response setting out committed actions and improvements - SPS and Scottish Ministers' Response to Sheriff Collins' Recommendations from the Katie Allan & William Lindsay or Brown FAI. Where this is the case, an update on progress has been incorporated into the response to reflect ongoing work and developments.

 

6. SPS recognise the importance of each recommendation. The full response below, sets out actions taken and timescale for further action:

 

7. Recommendation 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.

 

8. Response – Ensuring the physical environment is safe for everyone in our care remains of highest priority, and we are fully committed to identifying and eliminating, wherever possible, all potential ligature risks within Polmont. SPS are progressing compliance with this recommendation in line with Sheriff Collins’ Determination in the Inquiry into the deaths of Katie Allan and William Lindsay (Brown). Through collaboration with NHS expertise work on the bespoke toolkit to audit cells for ligature points is well underway.  The toolkit will be evaluated to determine its effectiveness in identifying ligature points.  An update has been provided to Scottish Ministers and SPS is working towards testing the toolkit at Polmont during summer 2025.

 

9. Recommendation 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.

 

10. Response – SPS recognises the concerns raised regarding the design of cell toilet cubicle doors and the importance of taking appropriate steps to reduce any associated ligature risks. SPS have completed a review of all toilet doors across its entire estate and due to the differences across the estate, have determined that there is not one single replacement solution. SPS has therefore identified alternative cell toilet doors, and each establishment will be considered separately. While a replacement door programme is being developed, Monro Hall where young people are placed within Polmont will be prioritised.  Already SPS has removed the cell toilet doors identified from those spaces where young people are located for their first 72 hours in Polmont.  A replacement cell toilet door programme is expected to commence in Polmont imminently with new, reduced ligature cell toilet doors being installed in the new admission 72-hour cells by October.

 

11. Recommendation 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.

 

12. Response – SPS recognises the critical role of the Death in Prison Learning, Audit and Review (DIPLAR) process in identifying opportunities for improvement and is committed to ensuring that all relevant factors including the physical environment and means by which a death occurred are thoroughly considered in every case. SPS have completed this recommendation in line with Sheriff Collins’ Determination in the Inquiry into the deaths of Katie Allan and William Lindsay (Brown).  Since October 2024, the DIPLAR process requires staff to include details of the environment in cases where the death was suicide by ligature, including recording the fixture point and ligature used. While this recommendation is complete, we continue to review the DIPLAR process ensuring it takes account of lessons learned.

 

Recommendations 4 and 5

13. Recommendation 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.

 

14. Recommendation 5 – TTM Guidance and training materials should be amended to make express reference to, and greater emphasise, 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.

 

15. Response – We have grouped recommendations 4 and 5 for the purposes of responding. While the Talk to Me policy plays a vital role in supporting individuals already identified as being at risk of suicide, SPS recognises its broader duty to intervene earlier before a young person reaches that point of crisis. We are committed to strengthening our approach to prevention, particularly where patterns of drug use may signal heightened vulnerability. SPS are currently undertaking a full overhaul of the Talk to Me policy and guidance, supported by dedicated resource and informed by an independent review due to conclude by the end of summer 2025. Central to this overhaul will be a stronger emphasis on recognising wider risk factors—such as substance misuse—that contribute to vulnerability. Work has commenced to review MORS which will consider the TTM review to ensure alignment of policies and processes.  Both reviews will consider these recommendations including the products and resources which would be required to incorporate them into the new policies.  Training and implementation of the overhauled Talk to Me policy will commence from January 2026. 

 

16. Recommendation 6 – A visual hatch check, around one hour before the end of the night shift, should be reintroduced at Polmont to seek to ensure that all young prisoners are safe and well within their cells at this time.

 

17. Response - SPS acknowledges our responsibility and priority to ensure the safety and wellbeing of all young people in custody at HMP & YOI Polmont. We also recognise the need to uphold human rights and dignity for the individuals in our care, particularly during periods of rest and privacy. The recommendation to reintroduce a visual hatch check approximately one hour before the end of the night shift requires detailed consideration to achieve the aim of ensuring young prisoners are safe and well. To support this, SPS will establish a short-term working group focused specifically on Polmont, tasked with developing an options appraisal for implementation that will take into account best practice and operational practice from other jurisdictions. As part of this work, an Equalities and Human Rights Impact Assessment will be undertaken to ensure that any proposed measures are, inclusive, and compliant with our legal and ethical obligations. The working group will report its findings to Scottish Ministers by the end of 2025.

 

18. Recommendation 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.

 

19. Response – SPS is committed to ensuring that HMP & YOI Polmont provides a safe, secure, and respectful environment for all young people in our care. A review of the 'Think Twice' anti-bullying and respectful behaviour policy is already underway. This review aims to strengthen our approach to addressing bullying and abusive behaviour and will contribute to ongoing efforts to promote a safer and more respectful environment within our establishments.

 

20. We recognise the importance of effective staff presence during patrol and night shifts in preventing and responding to incidents such as verbal abuse, bullying, drug-related activity, and physical disturbances. To support this, SPS will commission a review, to complement the wider review of the ‘Think Twice’ policy to examine the current instructions provided to staff, the effectiveness of existing patrol practices, and the adequacy of staffing levels during these periods. This review will also explore opportunities to strengthen our approach to night-time safety and supervision. A written report will be submitted to Scottish Ministers by 5 November 2025.

Concluding Comments

21. SPS remains deeply committed to learning from the tragic death of Jack McKenzie and to ensuring that meaningful, lasting change is delivered across our estate particularly at HMP & YOI Polmont to support wider learning and compliance.

 

22. We recognise the profound responsibility we hold in caring for young people at a time of vulnerability. The recommendations set out in this Determination have been met with careful reflection and a commitment to act at pace. Through our actions, we aim to strengthen our systems and safeguards, but to create an environment where every young person feels protected, valued, and treated with dignity and respect.

 

23. SPS are truly sorry for the loss of Jack McKenzie, our thoughts remain with his family. This response reflects our ongoing reflection and commitment to immediate action and systemic change.

 

 

Scottish Ministers

July 2025