Source · Scotland · Fatal Accident Inquiry
Brendan Reilly
Scotland — FAI
Custody
2 recommendations
Reference [2025] FAI 19
Published 25 April 2025
Determination
| Reference | [2025] FAI 19 |
| Published | 25 April 2025 |
| Sheriff | Sheriff N K Patrick |
| Sheriffdom | North Strathclyde |
| Date of death | 11 June 2021 |
| Location | HMP Kilmarnock |
| Cause of death | Etizolam intoxication |
Recommendations 2
PDF
HMP Kilmarnock
Scottish Ambulance Service
It is recommended that HMP Kilmarnock review the arrangements for ensuring and monitoring compliance with the roll count policies and procedures. It is recommended 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.
No mandatory response mechanism — unlike PFD reports (England & Wales), recipients are not required to respond.
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About FAIs
Fatal Accident Inquiries are held under the
2016 Act
before a sheriff. They are mandatory for deaths in custody and at work.
The sheriff may make recommendations under s.26(1)(b) but there is no enforcement mechanism.