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Sheriffdom of Sheriff Court SHERIFFDOM OF TAYSIDE CENTRAL AND FIFE AT ALLOA [2019] FAI 2 ALO-B83-17 DETERMINATION BY SHERIFF DAVID N MACKIE UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016 into the death of DANIEL McSWEENEY Alloa, 11 December 2018 DETERMINATION The Sheriff, having considered the information presented at the inquiry, determines in terms of section 26 of the Act that:- Daniel McSweeney, born on 27 March 1960, late of Glenochil Prison, Tullibody, FK10 3AD, died within Devon Hall Cell Block, HM Prison Glenochil at 09:15 hours on 29 September 2014. 1. In terms of section 26(2)(a) of the 2016 Act, Daniel McSweeney died within Devon Hall Cell Block, HMP Glenochil at 09:15 hours on 29 September 2014; 2. In terms of section 26(2)(b) of the 2016 Act the deceased consumed a quantity of Diamorphine amounting to an accidental overdose during the evening of Sunday 2 28 September or morning of Monday 29 September 2014. It is likely that, at the same time, he consumed a quantity of Benzodiazepines in the form of Diazepam and Diclazepam. His consumption of these illicit substances resulted in his accidental death. 3. In terms of section 26(2)(c) of the 2016 Act the death was caused by: a. Multidrug toxicity 4. In terms of section 26(2)(d) of the 2016 Act the cause of the accident resulting in the death of the deceased was his consumption of a quantity amounting to an overdose of illicit substances comprising mainly Diamorphine but probably including Benzodiazepines in the form of Diazepam and Diclazepam. 5. In terms of section 26(2)(e) of the 2016 Act there are no precautions which could reasonably have been taken that might realistically have resulted in the death or the accident resulting in the death being avoided had they been taken. 6. In terms of section 26(2)(f) of the 2016 Act there are no defects in any system of working which contributed to the death or the accident resulting in the death. 7. In terms of section 26(2)(g) of the 2016 Act there are facts which are relevant to the circumstances of the death relating to the investigation and detection of drug crime within Scottish prisons and these are discussed in paragraphs [101] to [108] of the Note. 3 RECOMMENDATIONS In terms of section 26(1)(b), for the reasons addressed in the body of the Note, there are no recommendations arising from this inquiry. NOTE Introduction [1] The Procurator Fiscal for the district of Tayside, Central and Fife gave notice on 9 August 2017 under section 15(1) of the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016 of the holding of an inquiry into the death of Daniel McSweeney who died within HM Prison Glenochil on 29 September 2014. The inquiry was mandatory in terms of section 2(4)(a) of the Act in respect that the late Mr McSweeney was in legal custody within HM Prison Glenochil at the time of death. [2] The matter called before the Sheriff at a preliminary hearing within Alloa Sheriff Court on 16 August 2017 at which time the Court considered it not appropriate to fix the date for the inquiry and ordered that a preliminary hearing be held on 3 October 2017. A further preliminary hearing was held on 17 November 2017 when a date was fixed for the start of the inquiry on 11 December with further dates reserved on 13 and 14 December all 2017. [3] The inquiry duly commenced on 11 December. It did not conclude by 14 December and was further continued to 21 February 2018. The hearing of evidence concluded on 21 February at which time the Sheriff adjourned the inquiry for a hearing on submissions on 2 May 2018. Parties were ordered to present written submissions. 4 [4] At the conclusion of the evidence on the third day of the inquiry on 14 December 2017 and in the exercise of the power conferred by section 20(2) of the Act I issued a Note requiring the Procurator Fiscal and Scottish Prison Service as participants to bring forward evidence about certain matters specified in my Note. Having already provided parties orally with some indication of the matters on which I considered further evidence was necessary at the conclusion of the second day, the Procurator Fiscal presented additional evidence on the third day. This went some way to addressing the points I had raised but for reasons I explained in a Second Note dated 15 December 2017 I considered that additional evidence was still required. The Notes are attached as Appendices. Participants and representation [5] The Crown was represented by the Procurator Fiscal Depute Ms Cook. The Scottish Prison Service was represented by Ms Phillips, Solicitor, the Prison Officers’ Association by Mr Gillies, Solicitor, the National Health Service by Ms Watts, Advocate and the family of the deceased by Ms McGowan, Solicitor. Witnesses [6] I heard the evidence of the following witnesses listed in the order in which they gave evidence: 1. Joan Reekie, former Lifer Liaison Officer and Early Release Liaison Officer, Scottish Prison Service; 5 2. Andrew McNally, Reception Officer, HM Prison Glenochil; 3. Kenneth Miller, Prison Officer, Segregation Unit, HM Prison Glenochil; 4. John Rae, Prison Officer, HM Prison, Glenochil; 5. Victoria McDonald, Specialist Nurse in Public Health, Sexual Health and Addiction Team Manager, HM Prison Glenochil; 6. Fiona Parker, Nurse Practitioner, HM Prison Glenochil; 7. Christopher Cochrane, Prison Officer, HM Prison Glenochil; 8. David Hugh Ross, former Night Shift Officer in Charge, HM Prison Glenochil; 9. Iain Hill, Prison Officer, HM Prison Glenochil; 10. William O’Hare, Prison Officer, HM Prison Glenochil; 11. Paul James O’Flaherty, Security Manager, HM Prison Glenochil; 12. Aileen Margaret Kidd, Staff Nurse, HM Prison Glenochil; 13. Dr. Michael Blackmore, Portfolio G.P., Forth Valley; 14. Karen Marie Livesey, Forensic Scientist; 15. DC Jamie Hughes, Police Service Scotland, Pro-active CID; 16. Gillian Agnes Walker, Head of Operations and Public Protection, Scottish Prison Service; 17. Lesley McDowall, Health Strategy and Suicide Prevention Manager, Scottish Prison Service; 18. Andrew Morin, Staff Nurse, Acute Assessment Unit, Forth Valley Royal Hospital, Larbert; 6 19. Inspector David Simpkins, Force Custody Inspector, Police Service Scotland; 20. Dr. Ian Hugh Wilkinson, Consultant Forensic Pathologist, NHS Lothian; 21. Dr. Fiona Wylie, Forensic Toxicologist, University of Glasgow; 22. Deborah Carmichael, Criminal Justice Social Worker, Glasgow City Council; 23. Dr. Adrian James McInnes, former Accident and Emergency Clinician, Forth Valley Royal Hospital, Larbert; 24. Detective Inspector Kenneth McAndrew, Police Service Scotland, Stirling and Forth Valley CID; 25. Derek Marshall, Unit Manager, Scottish Prison Service; [7] It cannot be said in relation to any of the witnesses from whom the inquiry heard evidence that any question of credibility arose. Limited observations regarding the reliability and content of the evidence of certain witnesses are contained within the summary to follow. [8] Certain facts were agreed amongst the parties participating and the Crown and are set out in the Joint Minute of Agreement in Process. The legal framework [9] This inquiry was held under section 1 of the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016, and its procedure governed by the Act of Sederunt (Fatal Accident Inquiry Rules) 2017 (SSI 2017/103). The purpose of an inquiry under s 1(3) of the Act is (a) to establish the circumstances of the death and (b) consider what steps, if any, might be taken to prevent other deaths in similar 7 circumstances. This Determination sets out my findings as to the circumstances mentioned in section 26(2)(a) to (d) of the Act, that is to say, when and where the death occurred, when and where any accident resulting in the death occurred, the cause or causes of the death, the cause or causes of any accident resulting in the death. The Determination further addresses in terms of subsection (2)(e) any precautions which could reasonably have been taken which might realistically have resulted in the death or any accident resulting in the death, being avoided. The question whether any defects in any system of working contributed to the death or any accident resulting in the death is raised by subsection (2)(f) of the Act and is addressed in this Determination along with consideration of other facts relevant to the circumstances of the death (subsection (2)(g)). [10] The inquiry was arranged by the Procurator Fiscal following investigation into the circumstances of the death of the late Mr McSweeney and in accordance with the responsibility conferred by section 1(1) of the Act. It was a mandatory inquiry in terms of section 2(4) of the Act as it concerned the death of a person who, at the time of death, was in legal custody, being a prisoner within HM Prison Glenochil. An inquiry is an inquisitorial process to address the matters specified above. It is not the purpose of an inquiry such as this to establish civil or criminal liability. [11] A Fatal Accident Inquiry is an exercise carried out in hindsight and with the benefit of hindsight. The terms of section 26(2)(e) require the Sheriff, so far as they have been established to his satisfaction, to set out the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided. The Sheriff 8 should not try to determine what precautions if any ‘would’ have avoided the accident for that would be an inappropriate quest for certainty. Nor should he enter the realms of what precautions ‘should’ have been taken for that would be to trespass into the field of blame.
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