Prison officers lined up “like a penalty shoot-out” to watch an inmate dying at a Scottish jail, it was claimed.
Allan Marshall’s death was described as “entirely preventable” – prompting politicians to demand answers over the incident.
The 30-year-old prisoner died after being dragged face down across the floor and restrained in a corridor by staff at Edinburgh’s Saughton jail in March 2015, the Daily Record reported.
In a shocking Fatal Accident Inquiry (FAI) ruling, Sheriff Gordon Liddle said Allan’s death from a cardiac arrest following restraint by five prison officers could have been avoided.
Allan – a small business owner – was awaiting trial over a breach of the peace outside a nightclub in Hamilton.
Shadow justice secretary Liam Kerr MSP last night led calls for further investigations into Allan’s death.
He said: “This is a truly awful case which leaves many questions needing to be answered.
“It is the duty of prison officers to ensure the well-being of inmates, yet alleged negligence has led to this man’s death.
“We need to find out exactly how this was able to occur in the first place, and put in measures to ensure it doesn’t happen again.”
In Sheriff Liddle’s report, he tells how witnesses described prison officers hitting and stamping on Allan before sharing information prior to a police investigation.
The sheriff said: “It was clear that prison officer staff did not tell the whole truth on a number of occasions. Sometimes they appeared to be mutually and consistently dishonest.
“Allan Stewart Marshall’s death was a tragedy. I am satisfied the evidence which has been led in this inquiry amply demonstrates that Mr Marshall’s death was entirely preventable.
“There were numerous opportunities over the period from the early hours of March 22, 2015, and the end of the restraint on March 25, 2015, when a decision by a prison officer to seek NHS Prison Medical Care assistance could have broken the chain of events.
“These were instances when better training of SPS staff could have made the difference. It has, in fact, been difficult to identify anything that went significantly well.”
In a harrowing account of the events leading up to Allan’s death, the prison nurse, identified only as KQ, said she responded to a “code blue” alert for medical assistance.
She found Allan injured and limp on his back in the corridor, while officers stood “in suspended animation”.
She described about 20 officers lined up beside Allan, “shoulder to shoulder like a penalty shoot-out”.
It is believed this was about at 8.28am but it is unclear when the code blue was triggered because the recording had been destroyed before it could be examined – a process the sheriff condemned.
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The nurse said she had to ask officers to move aside, so she could reach Allan and they ignored her protests to cease restraining him by the arms even as he lay unconscious.
Despite having first aid training, no officer had tried to resuscitate him, and when KQ asked what had happened and if they had called an ambulance, they “looked through her” in silence.
She said Allan, who was on remand for breach of the peace, “had injuries from head to toe”.
She told the FAI: “His tongue was enormous and hanging out of his mouth. He was pale and his ears were blue.”
The nurse had initially wondered if he had hanged himself.
The skin was “shaved off the top of his feet”. He had a “gaping cut over his eye, which had been bleeding” and there was dried blood in his eyelids and nose.
She managed to get Allan breathing but the sheriff said the medical evidence showed oxygen starvation to the brain directly caused his death, following his cardiac arrest.
Allan, who was from Carluke, Lanarkshire, and ran a recycling business, died four days later in the Edinburgh’s Royal
Infirmary after being placed in an induced coma.
It was claimed Allan had lashed out at officers while suffering an episode of “excited delirium” after being transferred to the jail’s segregation unit for smashing up his cell and covering it in excrement.
After an altercation in the shower, officers then dragged Allan out to the corridor, face down, feet first, despite video evidence showing he was barely struggling.
Officers contradicted each other on who laid hands on him first and there were no cameras in the showering unit.
Toxicology tests found no evidence of illegal drugs or legal highs in Allan, although prison officers testified that they suspected he had taken them.
The sheriff suggested Allan could have been left in the showers to de-escalate the situation.
The report said when officers placed plastic handcuffs on Allan, he may have already suffered a cardiac arrest.
Officers claimed Allan strained so hard against the plastic cuffs they turned from black to white due to being stretched but presentation of them in court showed this was not true.
The sheriff said it was “disturbing” that one prison officer, Steven Banks, gave “false evidence” about the cuffs turning white.
Though officers said he struggled with excessive strength, video evidence and restraint expert witnesses – including renowned self-defence professional Eric Baskind said Allan looked under officers’ control and was not fighting back.
The sheriff said he was “disturbed” to hear an inmate witness, RM, say he saw an officer “twisting the boy’s arm” in the corridor and another “hitting the boy in the ribs and the boy making a high-pitched scream”, before becoming a “dead weight on the floor”. RM said he had never seen restraint with such violence.
Forensic pathologist Dr Robert Ainsworth said Allan had an underlying heart condition which contributed to his death but it was possible his breathing was compromised by being held face down and that psychological stress of restraint could have increased the risk of cardiac arrest.
Prior to police interviewing the officers after the incident, they were allowed to congregate in a debriefing which the sheriff suggested had caused “cross contamination of evidence”.
The sheriff said there were “credibility issues” around the officers’ use of feet on Allan during the restraint, which experts said was not an approved method, “not justified” and could compromise breathing.
None of the officers told investigating police that feet were used and with only one exception, they told the FAI they hadn’t seen them being used – despite the video showing it happened at least 10 times.
No medics had been consulted despite protocol dictating they should, even when for two days Allan displayed symptoms of mental illness and psychosis, including paranoia and talking about God and Satan.
A Scottish Government spokesperson said it recognised “the importance of providing a safe and secure environment for those in custody”.
The Scottish Prison Service said: “We conduct a review of all deaths in custody to ensure that any lessons are learned promptly and any actions that require to be taken are taken.”
The Prison Officers Association (Scotland) were approached for comment.