A prisoner took his own life just two days after being remanded to Barlinnie jail.
Stephen Masson was found dead in his cell in D Hall days after being arrested in Glasgow city centre for attacking a police officer.
A Fatal Accident Inquiry heard that a prison guard found the 47-year-old's body just hours after he'd been told he wasn't on the list to receive methadone that day. The officer was not aware that Masson had previously attempted suicide a few months earlier.
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When he looked in Masson's cell during routine checks a short time later, the officer made the grim discovery and activated a code blue call for assistance, but despite the best efforts of staff and medics, he could not be saved.
Details of the inquiry were laid bare in Sheriff Gerard Considine's finding published this week.
The report explains the the 47-year-old was intoxicated when he was arrested and taken to Govan police station doctors assessed him as fit for detention on November 30, 2018.
He refused to answer during a police vulnerability assessment and was placed in a high risk category and under constant observation. Later the following day he decided to cooperate and explained that he was prescribed 70ml of methadone daily.
Police made at least two unsuccessful attempts to collect Masson's methadone prescription from a pharmacy, however, the inquiry heard that record keeping "could have been better".
On December 4, Masson appeared at Glasgow Sheriff Court where he pled not guilty and he was remanded to Barlinnie Prison with a date set for trial a month later.
After he was passed to Scottish Prison Service staff at the Glasgow jail later the same day he was processed and taken to his cell, where two days later he took his own life.
Three years on, the inquiry found that while no precautions could reasonably have been taken that might realistically have resulted in the death being avoided, although a defect in the system of working to ensure the provision of prescribed medication was identified.
Sheriff Considine recommended that a note of all ongoing prescriptions currently prescribed to a patient should be registered with the NHS, regardless of the prescriber to allow healthcare professionals immediate access to details of a patient’s medication.
He also pointed out that a clear and robust system should be put in place to ensure that all prescription medication is provided without delay to a prisoner once confirmation is received.
He explained the system should be in place before the end of each day, and where necessary to confirm if a reply has been received to ensure that a prisoner is receiving the correct medication.
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