List of failures that led to the death of young prisoners

The deaths of two young men in a young offenders’ institution could have been avoided but for a “list of failings” in the system, a sheriff has concluded.

Katie Allen, 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 unsafe both prisoners were at the Polmont facility near Falkirk.

In a critical assessment of the Scottish Prison Service and health services, the Sheriff also found that appropriate precautions could have been taken to avoid their deaths.

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

The Sheriff criticized this failure to happen in the years following Katie and William’s deaths.

Sheriff Collins found that William’s death resulted from a catalog of individual and collective failures by the SPS and health care staff at Polmont.

“Almost everyone who talked to him was at fault to some degree,” he said.

He said the appropriate precaution would have been to keep Williams – who had a history of attempting suicide – under observation.

He was removed from the comments the morning after arriving at a case conference. The sheriff also found that the cell he was held in could have been made safer for him.

Williams was arrested after walking into Glasgow’s Saracen Street police station armed with a knife.

Three days before his death he was remanded in custody as a “potential threat to public safety” because there was no space in the children’s secure unit.

In Katie’s case, the sheriff found that there were multiple failures by jail and health care staff to properly identify, record and share information related to her risk.

However, he said that despite the foresight, his death was spontaneous and unexpected.

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

There was a security problem in the cell about which SPS had been aware for a long time.

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

Her mother Linda said that when she was finally able to read the FAI report she felt “anger, relief, vengeance, pain and sometimes sadness”.

“Katie was brutalized at Polmont,” he said. “So much so that he lost all hope and saw only one solution – his own death.

“As one witness in her FAI claimed she was not ‘grown up’ – she was bullied, she was scared, she was lost.”

Families are now demanding an overhaul of fatal crash investigations to make their recommendations legally binding.

Linda Allen added: “The prison service literally gets away with creating the conditions that cause people to die prematurely, no sanctions exist, they cannot be criminally prosecuted.

“Unless this changes, another Katie or another William will lose their life. Three have already done so at Polmont since 2018.”

Katie’s 21-year-old brother Scott told BBC Scotland News he believed the justice system had killed her.

She said she was unsafe, abandoned and that the system designed to keep her safe had “destroyed” her.

In his report, Sheriff Collins criticized the failure to make the cells safer in the years following Katie and William’s deaths and said the cells should be audited and an improvement program implemented.

Other recommendations include:

• A pilot at Polmont for the use of technology such as heart rate monitors and respiratory monitors to screen patients in mental health units. It is already being used in other secure mental health settings.
• When a young person is remanded in custody all information available to the court, such as social work and health care reports, must be given to the Scottish Prison Service (SPS).
• A dedicated 24-hour telephone line should be set up for families to report concerns related to suicide risk, with such concerns promptly processed and recorded.
• Bullying concerns should be immediately and proactively shared with the senior prison officer on duty.
• SPS and Forth Valley Health Board should review their training and guidance on sharing information relating to young prisoners so that prison officers and health care 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 promptly reviewed by a mental health nurse and, where necessary, action is taken without delay.
• All youth must be kept under observation for at least 72 hours after admission and must not be removed until a decision is made at a case conference.

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 list of people calling saying ‘he’s going to do this, you need to keep an eye on him’,” he said.

“He was scared there, he was being bullied there and that was the last straw for him.

“She should not have been placed in Polmont. She should have been in a caring, safe environment but there was no place in any secure unit. She needed care and she needed love.”

Mr Cahill said: “Anyone who knew him and worked with him saw his mentality and knew what he was going to do.

“SPS and Polmont staff didn’t listen. We called and called and called and told them ‘don’t believe this guy if he says he’s not going to do it. He’s going to do it.’ ‘

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

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

A Scottish Prison Service spokesman said he “sincerely sympathizes and apologizes for the failings identified in this report”.

He added: “We are committed to doing everything we can to support people and keep them safe during the most challenging and vulnerable times of their lives.

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

Justice Secretary Angela Constance said Katie and William “should not have died while they were in the care of the state”.

He said: “Since the deaths of Katie Allen and William Lindsay in 2018, work has been done to reduce recidivism, including action by the Scottish Prison Service to remove ligature points in cells. However, the clear There is still a lot more to be done.” Must be done at speed.”

In a statement, NHS Forth Valley apologized for the failings relating to health services highlighted in the report.

It added: “Extensive action has been taken over the past six years to improve and strengthen prison health services and supports.”

The board said it would now consider the recommendations of this inquiry “to identify any actions or learnings to further improve prison health services”.

Scotland’s Solicitor General, Ruth Charteris Casey, said: “I would like to once again acknowledge the deep distress that Katie and William’s deaths have caused their families and appreciate that the wait for these proceedings has been too long .

“Since his death, the Crown Office and the Procurator Fiscal Service introduced reforms designed to reduce the time taken to investigate deaths, improve the quality of such investigations and improve communication with bereaved families Are.

“As part of these reforms, a specialist custodial death investigation team has been established to focus on cases like Katie and William.”