FAI reveals missed checks before prisoners death at HMP Kilmarnock

A Fatal Accident Inquiry has found failures in basic prison procedures after the death of an inmate at HMP Kilmarnock.

Brendan Reilly, who was serving a life sentence after stabbing another man to death, was found dead in his cell in June 2021.

A post-mortem revealed he died from a toxic mix of drugs including buprenorphine and etizolam.

The inquiry found that staff had not carried out proper roll call checks on the morning of his death.

Usual policy means that prison staff must receive a verbal response from prisoners while they are in their cells - but officers did not probe further when Reilly was unresponsive in bed.

They later returned to his cell to find his 7am alarm ringing and Reilly could not be saved by medics.

Sheriff Nicola Patrick said: “The prison policy and procedure relating to roll count was not complied with”, and that senior managers were “not aware of the lack of adherence”.

The determination also criticised the prison’s response to a previous warning, saying that a recommendation to improve emergency communication procedures had never been acted on.

It was revealed that the Scottish Ambulance Service had been unable to contact prison personnel during the incident.

Sheriff Patrick added: “There is no clear system for checking compliance” with safety procedures, and said an internal investigation had failed to consider this a relevant factor.

The Sheriff is now recommending two key changes: ensuring sure roll calls are being done correctly, and the introduction of a clearer process for calling emergency services quickly when needed.

However, it was ruled that there were no reasonable precautions which could have prevented his death.

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