Key Points
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Katie Allan, 21, and William Lindsay, 16, took their own lives at Polmont YOI in 2018 - Katie died while serving a sentence for a driving offence in June 2018
- William died in October the same year, two days after he was remanded at the facility
- Katie’s parents campaigned for five years for an fatal accident inquiry to be held
- Sheriff’s determination on Friday finds both William and Katie’s deaths were partly due to ‘systemic failures’
Systemic failures contributed to the preventable suicides of two people in Scotland’s young offender institution, a fatal accident inquiry has found.
Katie Allan, 21, and William Lindsay, 16, were found dead in their cells in separate incidents within months of each other at Polmont YOI near Falkirk in 2018.
Their deaths “might realistically have been avoided” if reasonable precautions had been taken, Sheriff Simon Collins KC said in his determination published on Friday.
He listed 25 recommendations that might realistically prevent other deaths in similar circumstances.
In Katie’s case, Sheriff Collins found there were multiple failures by prison and healthcare staff to properly identify, record and share information relevant to Katie’s risk in accordance with the Scottish Prison Service’s Talk to Me (TTM) suicide prevention strategy.
However, he found Katie’s death was spontaneous and unpredictable even with the benefit of hindsight.
“She had suffered distress as a result of and during her imprisonment, which had adversely affected her mental and emotional wellbeing, but had appeared resilient in the face of it,” Sheriff Collins said.
“She was supported by her family and by prison and healthcare staff. She did not say or do anything to suggest that she was contemplating suicide.
“The evidence did not establish that Katie should have been assessed as being at risk of suicide prior to her death and placed on TTM.”
In William’s case, Sheriff Collins found his death resulted from a catalogue of individual and collective failures by the Scottish Prison Service (SPS) and healthcare staff in Polmont.
“Almost all of those who interacted with him were at fault to some extent,” Sheriff Collins said.
Katie’s story
Family handoutKatie was a geography student at the University of Glasgow when she was jailed for 16 months after pleading guilty to drink driving and causing serious injury by dangerous driving.
She had drunk four pints of cider before trying to drive home from a pub in Giffnock, East Renfrewshire, in August 2017.
Katie pleaded guilty at Paisley Sheriff Court to causing serious injury by driving dangerously and driving at more than four times above the legal alcohol limit.
After her sentencing, she was initially held at Cornton Vale and it was recorded in her medical notes she had previously self-harmed and suffered from alopecia and eczema.
A few days later she was transferred to Polmont, where mental health nurse Alan MacFarlane wrote in a risk assessment she “presented well” on arrival and he had “no concern” about her “based on her current presentation”.
Katie was found dead in her cell at Polmont YOI on June 4, 2018. The fatal accident inquiry into her death heard she had been taunted and threatened by other inmates before taking her own life.
William’s story
Family handoutWilliam took his own life 48 hours after being sent to Polmont on remand despite being flagged as a suicide risk.
He spent most of his life in the care system – being in and out of care at least 19 times since the age of three.
On October 3, 2018, William walked into a police station with a knife, while on bail for another blade offence, the fatal accident inquiry heard in a statement of agreed evidence.
Despite a plea to bail him due to a lack of beds in a secure unit, he was remanded to Polmont after being deemed a “potential risk to public safety”.
Before he was taken there, William was asked by a social worker if he was suicidal and replied: “No, not now, but I don’t know how I’ll be in prison.”
Since 2016, William had been taken to hospital due to suicide attempts and ideation, excess drug use and fighting on 15 occasions in two years, and was initially put on a 30-minute observation at Polmont when he arrived “for reassurance and safety”.
On October 5, 2018, a case conference was held with a mental health nurse and two prison officers, where William was assessed as “at no apparent risk of suicide” and was removed from 30-minute observations – but less than two hours later was referred to the mental health team by a social worker.
William was found dead in his cell at 7.40am on October 7 – nearly 12 hours after having last had contact with SPS staff at 8.55pm.
SPSSheriff Collins found William’s death resulted from a catalogue of individual and collective failures by SPS and healthcare staff in Polmont.
“Reasonable precautions would have been for the case conference to have kept William on TTM, or in any event for him to have been reassessed and put back on TTM in the light of the further information later received by prison staff,” he said.
Sheriff Collins also said the system for actioning mental health referrals to the Forth Valley Health Board mental health team at Polmont was defective.
He cited an incident in which an emailed referral by a social worker about William on October 5 was printed out and placed in a filing tray by an administrator but not acted upon by healthcare staff until October 8, by which time William was dead.
Recommendations
Sheriff Collins recommended the SPS take steps to reduce the risk of suicide by removing harmful fixtures and fittings inside standard cells at Polmont.
He also said ministers should establish a system to ensure that all written information and documentation available to a court when a young person is sent to custody is passed to the SPS at the time of their admission.
STV NewsFurthermore, the SPS should provide a dedicated 24-hour telephone number for families to report any concerns they have relevant to the suicide risk of a prisoner and put in place a system to ensure that such concerns are immediately acted upon and recorded.
The SPS is currently reviewing the TTM policy, but the inquiry recommends that it be extensively revised.
Sheriff Collins stressed that greater emphasis should be placed on protecting young prisoners from suicide, particularly in the early stages of custody. A more precautionary approach was required.
‘They were in the care of the state and they should not have perished’
More than 100 prisoners in Scottish prisons have died by suicide since 2011 – ten of those have been young prisoners in Polmont.
The 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.
Justice secretary Angela Constance said she was deeply sorry for Katie and William’s deaths.
“They were in the care of the state and they should not have perished,” she told STV News.
“I’m also deeply cognisant of the journey these families have had to endure in terms of the process of finding answers.
STV News“The commitment that I give as the cabinet secretary for justice is to take on each and every recommendation made by Sheriff Collins and give a full response to parliament, but also acknowledge and accept the findings, the determination, of this sheriff – that the deaths of these two young people could have been prevented.
“Our system let these two young people and their families down. It is now my job to turn what the sheriff describes as systemic failures into systemic improvements.
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.”
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