Catalogue of failures led to young prisoner deaths at Polmont, says sheriff

The deaths of two young people at a young offenders’ institution could have been avoided but for a “catalogue of failures” in the system, a sheriff has concluded.

Katie Allan, 21, and William Brown, 16, also known as William Lindsay, took their own lives in separate incidents at Polmont Young Offenders Institution in 2018.

A fatal accident inquiry heard how both inmates were vulnerable while at the Polmont facility near Falkirk.

In a damning assessment of the Scottish Prison Service and healthcare services, the sheriff also found reasonable precautions could have been taken to avoid their deaths.

Sheriff Simon Collins KC has made 25 recommendations, including for the prison service to make definite and practical steps to make cells safer.

The sheriff criticised the failure for this to happen in the years since Katie and William’s deaths.

Sheriff Collins found that William’s death resulted from a catalogue of individual and collective failures by SPS and healthcare staff at Polmont.

He said “almost all of those who interacted with him were at fault to some extent.”

He said a reasonable precaution would have been to have kept William – who had a history of attempting suicide – on observations.

He was removed from observations the morning after he arrived at a case conference. The sheriff also found that the cell he was accommodated in could have been made safe for him.

William had been arrested after walking into Saracen Street police station in Glasgow while carrying a knife.

He was remanded in custody after being deemed a “potential risk to public safety” three days before his death because there was no space in a children’s secure unit.

In Katie’s case, the sheriff found that there were multiple failures by prison and healthcare staff to properly identify, record and share information relevant to her risk.

However, he said that even with the benefit of hindsight, her death had been spontaneous and unpredictable.

Sheriff Collins found that if the Glasgow University student’s cell had been made safe – which could have been done without significant cost – her death would not have happened.

There was a safety issue with the cell that had long been known to the SPS.

Katie was serving a 16-month sentence for dangerous and drink driving following a hit-and-run.

Her brother Scott, 21, told BBC Scotland News he believed the justice system had killed her.

He said she was vulnerable, abandoned and “destroyed” by a system meant to be keeping her safe.

In his report, Sheriff Collins criticised the failure to make cells safer in the years since Katie and William’s deaths and said there should be an audit of cells and an improvement programme implemented.

Other recommendations include:

• A pilot at Polmont for the use of technology, such as heart rate monitors and respiratory monitors, to check patients in mental health units. This is already being used in other secure mental health settings.
• All information available to the court when a young person is sent to custody, such as Criminal Justice Social work reports and other reports by healthcare services and other agencies, should be passed to the Scottish Prison Service (SPS).
• A dedicated 24-hour telephone line should be set up for families to report concerns they have relevant to suicide risk and a system should be put in place to ensure such concerns are immediately acted upon and recorded.
• Bullying concerns should be promptly and proactively shared with the senior prison officer on duty where the prisoner is located.
• SPS and Forth Valley Health Board should review their training and guidance on sharing information relating to young prisoners so prison officers and healthcare staff are aware of all relevant issues.
• Forth Valley Health Board should implement a system to ensure that referrals made by the mental health team at Polmont are immediately reviewed by a mental health nurse and, where necessary, acted on without delay.
• Forth Valley Health Board should provide further training to staff at Polmont on the importance of accurate record keeping.
• All young people should be put on observation for a minimum of 72 hours following admission and should not be removed until a case conference has decided that.

William’s former youth worker, Niall Cahill, told BBC Scotland News that Polmont had been repeatedly informed about the teenager’s background.

“We had a catalogue of people phoning, saying ‘he will do this, you need to keep an eye on him’,” he said.

“He was scared in there, he was getting bullied in there and that was the final straw for him.

“He should not have been placed in Polmont. He should have been in a caring, secure environment but there were no spaces in any of the secure units. He needed care and he needed love.”

Mr Cahill added: “Everyone who knew him and worked with him had seen his mindset and knew what he was going to do.

“SPS and Polmont staff didn’t listen. We phoned and phoned and phoned and told them ‘do not believe this boy if he says he isn’t going to do it. He is going to do it’.”

Mr Cahill said William, who spent most of his life in the care system and had lived in 27 different placements, had told his half-sister he was being bullied by prison officers and inmates at Polmont and was “terrified”.

According to his medical notes, William had thought about or attempted to take his own life on 14 occasions.

A Scottish Prison Service spokesperson said: “Our thoughts remain with the families of Katie Allan and William Lindsay.

“We are committed to doing everything we can to support people and keep them safe during one of the most challenging and vulnerable periods of their life.

“We are grateful to Sheriff Collins for his recommendations, which we will now carefully consider before responding further.”

In a statement, an NHS Forth Valley spokeswoman said: “We would like to offer our sincere condolences to the families of Katie Allan and William Brown and apologise for the failures relating to healthcare services highlighted in the report.

“A wide range of actions have been taken over the last six years to improve and strengthen prison health services and support.

“We continue to work in partnership with the Scottish Prison Service to ensure everything possible is done to support the mental health and wellbeing of young people.”

The spokeswoman added that the board had addressed the healthcare-related recommendations from the previous Expert Review on Mental Health Services for Young People at HMP YOI Polmont and would now consider the recommendations from this inquiry to identify any actions or learning to further improve prison healthcare services.

The 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.”

She added: “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.

“I hope that these proceedings provided the families with the answers they sought, and the sheriff’s determination helps to prevent similar deaths in the future.”

The determination also found that available evidence suggested that the rate of suicide by prisoners in Scotland may be one of the highest in Europe – and that it may be increasing – although the data is incomplete.