Deaths in custody at Polmont YOI could have been avoided, inquiry finds
Katie Allan, 21, and William Brown, 16, also known as William Lindsay, separately took their own lives at the facility in 2018.
The deaths of two young people who took their own lives while in custody in a young offenders institution “might have been avoided” and systemic failures contributed to the deaths, an inquiry has found.
Katie Allan, 21, and William Brown, 16, also known as William Lindsay, took their own lives within months of each other while held at Polmont YOI in 2018.
Ms Allan, a student at Glasgow University, was found dead in her cell on June 4 while serving a 16-month sentence for drink-driving and causing serious injury by dangerous driving.
Mr Brown, who had been in care repeatedly, was found dead in his cell on October 7, three days after being admitted as there was no space in a children’s secure unit, having walked into a police station with a knife.
A fatal accident inquiry (FAI) into their deaths was held at Falkirk Sheriff Court last year, led by Sheriff SG Collins KC.
In his determination, which was published on Friday, Sheriff Collins described a “catalogue of individual and collective failures by prison and healthcare staff” at the facility.
He found there were reasonable precautions by which both deaths might realistically have been avoided, and that systemic failures contributed to them.
One of the main issues, he said, was the effectiveness of the Talk To Me (TTM) suicide prevention strategy, through which at-risk prisoners are subjected to increased observation and checks.
He said Ms Allan had not been considered a “risk” when she was admitted to Polmont and so was not placed on TTM.
However, he said that during her incarceration there was a “systemic failure” by prison staff to complete “concern forms” that could have triggered the TTM process, pointing to a number of incidents recorded by prison staff that should have been red flags.
These included, he said, the fact Ms Allan was being bullied by other prisoners, distress caused by hair loss resulting from alopecia, her distress at being body (strip) searched by prison staff, and the failure of her appeal against her conviction.
Her weight also dropped from 65kg to 58kg during her 12 weeks at the facility, which Sheriff Collins said should have been a “cause for concern” by staff.
Mr Brown was placed on TTM on admission to Polmont only to be removed from it the next morning, despite presenting as a “very high risk” individual.
He was also not placed back on TTM when “further information” about his level of risk was provided to prison staff by a social worker later that day.
Sheriff Collins said: “Had Katie been put on TTM on the night of June 3-4, 2018, and had William not been removed from it prior to the night of October 6-7, 2018, there was a realistic possibility that their deaths might have been avoided.”
The sheriff also described as “defective” the systems for sharing information between the Scottish Prison Service (SPS) and other bodies, including courts and external agencies, about prisoner risk.
He also found issues with the way risk assessment information was recorded on prison systems.
This meant, he said: “There was no single, readily accessible source of all the information relevant to Katie’s risk of suicide which was available to SPS staff in Polmont.”
He added the deaths could have been prevented if “reasonable precautions” had been taken around the safety of cells, including the carrying out of regular checks to identify potential risks.
This would, he said, “restrict” the level of risk to inmate safety, “whether or not they are subject to TTM”.
Sheriff Collins’s report, which runs to more than 400 pages, sets out 25 recommendations “which might realistically prevent other deaths in similar circumstances”.
Concluding it, he said: “In common with all the participants in the inquiry, I offer my condolences to the families of Katie and William.
“I would wish to particularly acknowledge the contributions of Linda and Stuart Allan, at least one of whom attended every day of the inquiry, and whose dignity and courage were evident throughout.”
An SPS spokesperson said: “Our thoughts remain with the families of Katie Allan and William Lindsay and we would like to take this opportunity to offer our sincere condolences and apologies for the failures identified in this report.
“We are committed to doing everything we can to support people and keep them safe during the most challenging and vulnerable periods of their lives.
“We are grateful to Sheriff Collins for his recommendations, which we will now carefully consider before responding further.”
Justice Secretary Angela Constance said: “My deepest sympathies and condolences are with the families of Katie Allan and William Lindsay, who have lost a child and sibling.
“I am deeply sorry about their deaths and that their families have had to wait so long for the conclusion of this process.
“I fully appreciate that this has been an arduous process and will have compounded the trauma and distress of the families.
“Deaths from suicide in custody are as tragic as they are preventable, and the deaths of these two young people should not have happened whilst they were in the care of the state.”
Solicitor General for Scotland, Ruth Charteris KC, said: “I would again wish to acknowledge the deep anguish that the deaths of Katie and William have brought to their families and appreciate that the wait for these proceedings has been too long.
“Since their deaths, the Crown Office and Procurator Fiscal Service has introduced reforms designed to reduce the time it takes to investigate deaths, improve the quality of such investigations, and improve communication with bereaved families.
“As part of these reforms, a specialist custody deaths investigation team has been set up to focus on cases such as those of Katie and William.
“There is much more that can be done across the whole of the justice system to improve how deaths in custody are investigated, and the Crown is committed to contributing to that.”
