FAI: No precautions could have prevented prisoner death at HMP Perth

Sheriff Jennifer Bain KC has issued her determination following a fatal accident inquiry into the death of Reese Fairgrieve, 23, who died at HMP Perth on 13 September 2020.

Mr Fairgrieve was a prisoner at HMP Perth. He died between approximately 0400 and 1100 on 13 September 2020. The precise time of his death being unknown. At 1059, Mr Fairgrieve’s cell mate attempted to rouse him and found him “cold to the touch”. He activated the alarm but Mr Fairgrieve’s life was pronounced extinct at 1134.

A post-mortem examination identified the cause of death as the combined adverse effects of Etizolam, 4F-MDMB-BINACA, 5F-MDMB-PICA and Tramadol.
 
Sheriff Bain found that a cell check carried out by the Scottish Prison Service (SPS) at 0719 on 13 September 2020 was not performed in line with SPS policy. The check by prison officers failed to ensure that Mr Fairgrieve was safe and well. 

The sheriff has issued the following recommendations:

i. SPS should revise their national and refresher training in relation to locking / unlocking and numbers checks procedures to ensure that it accords with the realities of conducting such checks. To be effective, this training should be developed with sufficient input from operational staff, specifically governors, frontline managers and residential officers, and should reflect what is required of officers and what they are likely to encounter in the various cell types within the prison estate. Such national training should only be implemented once it has been approved at a prison governors meeting chaired by the Operations Director of SPS

ii. SPS training, policy and guidance materials in relation to locking / unlocking and residential numbers checks should be amended so that they are unambiguous and consistent with each other in relation to what is required of officers during these checks. Greater emphasis should be placed on the welfare aspect of the cell checks and the heightened risk of prisoner death in the event of non-compliance.

iii. Prison officers should be required to keep a contemporaneous documentary record of each cell check. The flatboard which is currently available and updated for each check, and which informs as to which prisoner is in which cell, should be revised to include a thumbnail image of each prisoner along with space to record which officers conducted the check, that the presence and identity of each prisoner within each cell has been confirmed and that a verbal response sufficient to ascertain the welfare of each prisoner has been received.

iv. Further provision should be made for compulsory ongoing refresher training at regular intervals to ensure that officers remain fully cognisant of the policies in place and the necessity of strictly adhering to the cell check procedures to ensure prisoner safety.

v. All such training should be centrally recorded and only such officers as have received the appropriate training and are aware of the SPS policies in relation to cell checks should be appointed to the role of residential officer.

vi. Where CCTV is available it should be reviewed at specified intervals by governors or other senior officials to ensure the cell checks are being implemented in the manner prescribed. This is necessary to mitigate against the occurrence of further deaths in custody. In the event of non-compliance, the offending officers should be debriefed, sanctions imposed if necessary and corrective training required.