Inquiry told young prisoner's suicide 'not preventable'

The death of a 20-year-old inmate in his cell at Polmont Young Offenders Institution could not have been prevented, a fatal accident inquiry (FAI) has heard.

Jack McKenzie took his own life on 3 September 2021, just hours after he was passed the drug etizolam.

He had been on remand at Polmont for rape and sexual assault charges - which he denied - since January of that year.

The FAI follows the joint inquiry into the deaths of Katie Allan, 21, and 16-year-old William Brown.

Katie and William - who was known as William Lindsay - took their lives in the institution in 2018.

The purpose of an FAI is to establish whether these deaths could have been prevented.

It will also examine what precautions could be taken in future to try and stop young people from taking their own lives in prison.

Sheriff Simon Collins, who has heard both inquiries, will receive further submissions on Mr McKenzie’s case.

He is expected to make recommendations for change when he delivers his determination into the circumstances of all three deaths later in the year.

The FAI previously heard Mr McKenzie was described by prison officers as happy and had a good rapport with the staff.

His family said he had misused substances in Polmont and had been put on a programme to manage substance misuse 14 times in seven months while he was in custody.

On 1 September 2021 Mr McKenzie had been due to attend court and thought there was a chance he was going to be released.

But during the day he became agitated and was assessed as being under the influence of an illegal substance.

He was placed on observations in Monro Hall and was also put into isolation where he was only released from his cell for around 20 minutes in a 24-hour period.

Mr McKenzie was meant to see his solicitor that afternoon but could not as he was on observations.

He was later removed from drug observations but remained in isolation.

The inquiry heard Mr McKenzie had been passed a line of etizolam into his cell in the early hours of 3 September and had been shouting from the windows.

The FAI heard a prison officer should have checked he was in his cell at 06:30.

But the officer looked through the hatch and assumed he was elsewhere.

At the next check, at about 07:30, the 20-year-old was found dead.

On Friday, Falkirk Sheriff Court heard the final oral evidence in the inquiry.

Dr Duncan Alcock, consultant forensic psychiatrist at the State Hospital at Carstairs, reviewed Mr McKenzie’s case.

In relation to how he was treated by staff and how they engaged with him for dealing with substance misuse, he said: "I don’t think anything further could have been done."

Another consultant psychiatrist, Dr Laurence Tuddenham told the FAI that, in his opinion, Mr McKenzie's suicide was "not preventable".

The expert added: "He had no history of thoughts of self-harm, acts of self-harm or suicide attempts either in prison or the community, prior to his suicide.

"I think he received adequate care seen by mental health and addiction staff."

However, the inquiry previously heard there were dangers in taking what a prisoner said at face value in risk assessments.

And, in relation to the drugs misuse policy, Sue McAllister, former director general of the Northern Ireland Prison Service, said: "Shortcomings were frequently found in reports and there was an over reliance on self-reporting."

The inquiry heard in 2018 a risk assessment report had highlighted that the bathroom doors in Monro hall could be used as a ligature point.

Three years on nothing has been done in relation to reduce that risk.

The court was also told night shift officer David Nelson breached patrol duty orders by not carrying out a proper hatch check.

He accepted if he had done his check properly he could have potentially saved Mr McKenzie's life.

The FAI previously heard from his aunt Caroline Wright, who he mainly lived with until just before he was remanded.

In a statement read in court she said: "I was very close to Jack.

"I think about him every day.

"I still cannot believe he is no longer with us."

She also said her nephew, who had previously been involved with gangs in the east end of Glasgow, told her he did not commit the offences for which he was remanded.

Mr McKenzie's brother Steven said in his affidavit that the two grew up together until the death of their grandmother, who they lived with, in May 2012.

At the time Steven was about 17 and his brother was about 12.

They remained close for another five years.

Steven said: "Jack did get into bother with the police due to the way he had been brought up and he did go about with a bad crowd."

He also told the court that his brother, who he described as "very kind", was "always very clear he was innocent".

Steven added: "I miss Jack every day and I cannot believe he is no longer here."