Staff shortages may have played a part in the death of an “at-risk” inmate in his cell at HMP Grampian.
The north-east jail has suffered from well-publicised workforce problems in recent years.
On the day 54-year-old Brian Buchan died, he should have been subject to checks by officers at the Peterhead facility every 15 minutes.
The remand prisoner had been found to be smoking heroin, and medical staff had concerns over his condition.
But, with the prison being short of three officers, Mr Buchan went more than an hour without being checked.
He died in July 2017 after he was found alone in his cell, unconscious and not breathing.
The cause of death was intoxication of methadone, a heroin substitute, and tranquilisers.
In her report into the prisoner’s Fatal Accident Inquiry, Sheriff Christine McCrossan found that the staff shortage was a “relevant” factor in his death.
She added: ”While Mr Buchan’s life may not realistically have been saved had the observations been carried out, his chances were clearly diminished if the observations did not take place.”
The report stated: “It appeared that Mr Buchan may have been hoarding diazepam, there was evidence indicating that Mr Buchan had come into possession of illicit drugs and drug paraphernalia.
“On the day of Mr Buchan’s death there was a shortage of prison staff on duty within Ellon hall, while Mr Buchan had been placed under observation on the day of his death due to substance misuse concerns, the mandated observations were not carried out in accordance with the care plan.”
The inquiry heard that the inmate was found to be “drowsy” at 11am on the day he died, but “had no other signs of substance misuse” and was initially placed on hourly observations.
At noon he was found to be lying on the floor of his cell having been sick. But medical staff found his blood pressure, pulse and oxygen levels to be acceptable.
He denied taking any illicit substance and was able to converse with his pupils appearing normal. However, he was then placed on 15 minute observations.
This continued until 1.39pm, by which time he was “drowsy but responsive”. But he was not checked again until 2.45pm – when he was found not to be breathing. He was pronounced dead at 3.16pm.
Sheriff McCrossan added: “The evidence indicates that the shortage of staff is likely to have played a significant part in the failure to carry out the observations.
“I make this point as it is relevant in assessing whether there were any precautions which could reasonably have been taken which might realistically have resulted in Mr Buchan’s death being avoided.”
She stressed that the individual officer responsible had been “engaged in other duties and was observed to be working diligently with other prisoners”.
A spokeswoman for the Scottish Prison Service (SPS) said: “The SPS conducts 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 safety and wellbeing of everyone in our care continues to be a priority for SPS and work is already under way to strengthen the support available.
“The Scottish Prison Service takes all instances of self harm and threats to self-harm very seriously and we constantly review our processes to ensure those at risk are identified and supported effectively.
“Our staff take very seriously the responsibility they have to care for those sent to them by the courts. They work tirelessly to achieve the best outcomes they can for those passing through their care.”