Fatal Accident Inquiry into the death of Daniel McSweeney

The following is a summary of the determination of Sheriff David N Mackie in the Fatal Accident Inquiry into the death of Daniel McSweeney, who died on 29 September 2014 at HM Prison Glenochil.

The late Daniel McSweeney was 54 years old when he died on 29th September 2014. He spent most of the last 13 years of his life in prison where he seemed secure and relatively at ease. At liberty in the community, by contrast, he seemed to struggle with independent life and was inexorably drawn to antisocial and criminal behaviour. The abuse of illicit substances played a significant part in his life and, ultimately, his death. 

An opportunity of parole was offered to the late Mr McSweeney and he was released on licence on Tuesday 2 September 2014, two months before the end of his sentence. Within a matter of a few days he was self-reporting that he was in breach of his licence and asking to be re-admitted to HM Prison Glenochil. There was a strong suspicion that Mr McSweeney intended to smuggle illicit substances into the prison concealed inside his body. 

Mr McSweeney presented himself at HM Prison Glenochil during the afternoon of Friday 19 September 2014, ten days before his death. His management proceeded upon the suspicion that he was “packing” illicit substances. By the time he reached his cell within Devon Hall Segregation Unit he had undergone two strip searches and the cell was cleared as sterile. He was placed on an hourly watch because of the suspicion that he was carrying illicit substances inside his body. The hourly watch consisted of officers observing him through the spy hole in the cell door. They were not expressly required to elicit a response from him. The arrangements for his observation remained the same for the remaining days leading to his death. 

Within two days a quantity of Heroin was discovered in his cell within the Segregation Unit. He experienced an overdose of Heroin some days later on 27 September 2014 for which he had to be admitted to hospital as an emergency. The only inference could be that on both occasions he had accessed drugs from within his own body for consumption. Against the strongest possible medical advice, including about the risk of death, he insisted upon discharging himself and was returned, after another strip search, to the segregation unit at HM Prison Glenochil. He was kept on an hourly watch. 

At about 07:20 a.m. on the morning of Monday 29 September 2014 Mr McSweeney was found to be unresponsive. Officers entered his cell where he was lying on his back with the cover drawn up to his bare chest. There was nothing medical staff could do to revive him and at 09:15 a.m. the doctor declared life to be extinct. 

The system of Health Care Markers within HM Prison Glenochil that led to Mr McSweeney being placed on an hourly watch was imperfect in 2014 and lacked precision as to whether on duty officers should or should not elicit a response. Mr McSweeney was observed on more than one occasion during the night to be breathing. He was breathing at 06:15 in the morning but apparently lifeless just over an hour later. The Sheriff considered this aspect and decided that the only proper conclusion was that there was no evidence before the inquiry to suggest that a regime that included a requirement to elicit a response from Mr McSweeney might have resulted in death being avoided. 

It emerged, however, that the Scottish Prison Service was already reviewing the practices and procedures related to the issuing of Health Care Markers and the conduct of observations on prisoners. In the most important respects relevant to this inquiry the guidance to officers contained in the new policy document addressed the points of possible concern. 

The current arrangements, which were implemented just months after the death of the late Mr McSweeney, provide for much greater clarity and precision as to the frequency and nature of observations to be carried out upon prisoners. The system is now more robust and supported by a coherent arrangement for record-keeping including an element of central oversight at Headquarter level. 

 The Sheriff was satisfied that any possible recommendations that might have arisen from consideration of the previously imperfect arrangements for the issuing of Health Care Markers have been more than adequately addressed by the comprehensive regime now in place. 

The autopsy disclosed that Mr McSweeney died of multi drug toxicity consisting, mainly, of an overdose of Diamorphine (Heroin) but other drugs similar to Valium were present as well and may have played a part. 

Twelve condom packages were found in the stomach and bowel of the late Mr McSweeeny that he had either swallowed or inserted. Most contained Diamorphine (Heroin) in powder form but a small number contained Benzodiazepine drugs similar to Valium. One contained SIM cards. There were no signs that any of the packages had burst or leaked and the Sheriff concluded that Mr McSweeney’s drug poisoning was the result of his having accessed drugs from within his own body and ingested them. He further concluded that the overdose was accidental and unintentional. 

The Heroin alone had a prison value of up to £81,000 and would have been regarded by the police as a significant find in the prosecution of drug crime. By the time of his first overdose and discharge from hospital there were the strongest possible grounds for suspecting that a serious crime related to concern in the supplying of illicit substances was being committed in plain sight and yet no consideration was given to reporting the matter to the Police. 

The inquiry heard evidence about a practice followed by both Police Service of Scotland and the Scottish Prison Service that the Prison Service will not report a suspected drug crime to the police and the police will not investigate a suspected drug crime within a prison upon the basis of a suspicion only, no matter how strong or reasonable the grounds for suspicion might be. The police will only investigate such a matter within a prison if there has been a physical recovery of illicit substances or related paraphernalia such as mobile telephones and SIM cards or both. 

This approach becomes self-defeating for a suspect like the late Mr McSweeney who had significant dealing quantities of illicit substances concealed within his body, inaccessible by any means of search, since the Scottish Prison Service protocol for intimate searches, unlike the police, stops short of supervision in the cell or at the toilet thus offering suspects the opportunity of repeatedly concealing items by swallowing or insertion until released into the general prison population. The phenomenon of repeat concealment was well recognised. 

The Sheriff thought this approach to be incongruous because the law governing detention and search of persons suspected of drug crime is based on whether there are reasonable grounds for suspicion, taking account of all of the surrounding facts and whether drugs are found or not. This begs the question why, between them, the Police Service for Scotland and Scottish Prison Service have raised the bar for the investigation of drug related crime within prisons to a higher and unnecessarily challenging level. 

The prison drug trade has damaging consequences well beyond the prison walls into the wider community. It affects not only prisoners and former prisoners who have been directly involved in the trade but also their families and the victims of crime. The glimpse this case of the late Mr McSweeney has offered of the prison drug trade suggests that it is a thriving and lucrative trade for the organised criminals and crime groups who operate it and a safe one in which there seems little risk of prosecution. What effect does that have in sustaining those groups and enabling them to perpetrate other forms of organised crime within the wider community? 

A situation appears to have been reached whereby reasonable grounds for suspicion of the commission of serious drug crimes that would be assiduously pursued in the wider community are not investigated inside the Scottish prison estate. To quote more than one witness from the Police Service of Scotland and Scottish Prison Service, “It doesn’t happen”. The case of the late Mr McSweeney is but one example. 

The full determination can be accessed via the Scottish Courts and Tribunals website.

Notes to editors

This summary is provided to assist in understanding the sheriff’s determination. It does not form part of the reasons for the decision. The full determination is the only authoritative document.