Jack McKenzie was aged 20 and a prisoner on remand at Polmont Young Offenders Institution who died by suicide in September 2021.
Unlike a criminal trial, an FAI seeks to establish the facts surrounding the death and is not a hearing which apportions blame.
The purpose of an inquiry is to establish the circumstances of the death and to consider what steps, if any, may be taken to prevent other deaths in similar circumstances.
Seven recommendations for change, including on actions to reduce risks of ligature anchor points, have been made in Sheriff Collins KC’s determination.
The Procurator Fiscal, who acts in the public interest, led expert evidence on the facts and circumstances of Jack’s death at the FAI in which other interested parties were represented.
Following the publication of the determination, Procurator Fiscal Andy Shanks, who leads on fatalities investigations for COPFS, said:
“The sheriff’s determination, which makes significant recommendations in relation to ligature anchor point identification, reduction and prevention and the checking of cells, is extensive and detailed.
“The FAI followed a thorough and comprehensive investigation by the Procurator Fiscal who ensured that the full facts and circumstances of Jack’s death were presented in evidence. "
“My thoughts remain with Jack’s loved ones at this difficult time.”