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Fatal Accident Inquiry into the Death of Angus MacDonald Malone, Sheriff John Craig Cunningham McSherry, Dunfermline Sheriff Court, 14th October 2009


In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Angus McDonald Malone died in Male Observation Cell 14, Dunfermline Police Station, Holyrood Square, Dunfermline between 00.43 and 07.55 hours on 13th August 2007. In terms of section 6(1)(b), the cause of death was the adverse effects of Morphine and Diazepam. Formal determinations were made under section 6(1)(c), (d) and (e).
Mr Malone was arrested on Friday 10th August 2007 and charged with wasting police time. Controlled drugs were found in his house. On arrival at the police station he was inadequately strip searched. Over the course of the weekend he made several statements to police to the effect that he had taken diazepam tablets and heroin which he had secreted in his rectum. He was found with faeces on his hands and had empty wrappers in his possession. However, these remarks were not correctly noted or acted upon, although a doctor did attend the deceased on the 11th August following one of his claims. The doctor concluded that Mr. Malone had not consumed drugs. Mr Malone was found unresponsive in his cell at 7.55am on the 13 August 2007. Efforts were made to revive him, but to no avail.
In terms of s.6(1)(c), Mr Malone's death could have been avoided if, on 10th August 2007, a thorough strip search was carried out when he was initially taken into custody. Another strip search should have been carried out on 12th August 2007 when Mr. Malone claimed to have taken drugs and to have stored them in his rectum. A search should also have been made of his cell at that time. The Force Medical Examiner should have been summoned to attend immediately to examine and question Mr Malone.
In terms of s.6(1)(d), the defects in the system of working which contributed to Mr Malone's death were: the lack of a consistent approach to the communication of information; the lack of full and accurate recording of all visits; the lack of clear guidelines when contacting an FME to attend; the lack of adequate training for Custody staff on drugs related matters; and that there was an inadequate number of Custody staff on duty.
In terms of s.6(1)(e), facts relevant to the circumstances of the death are: that his death was caused by voluntary consumption of a mixture of drugs; and that there have been improvements in custody care since the death of Mr Malone.