Jack McKenzie

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; b. Use the foregoing toolkit to conduct an audit of potential anchor ligature points within all standard cells; 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, repair or replace same so as to remove or at least reduce the risk of ligature arising therefrom as soon as practicable; and thereafter institute a policy of regular ongoing cell audit; ii. As regards any ligature anchor points arising from the inherent nature of fixtures or fittings, develop and publish a plan for their phased removal, replacement or modification, specify a timeframe, commence implementation beginning with the highest risk, and publish annual reports of progress; d. Ensure that proposed fittings and fixtures in any new build or refurbished cells are audited using the said toolkit at the planning stage. 2. All cell toilet cubicle doors of the type identified 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. 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. 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. 5. TTM Guidance and training materials should be amended to make express reference to, and provide greater emphasis on, 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. 6. A visual hatch check, around one hour before the end of the night shift, should be reintroduced at Polmont, in order to seek to ensure that all young prisoners are safe and well within their cells at this time. 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.