FAI DETERMINATION SUMMARIES

Warning: This summary and FAI determination discusses suicide. If you are affected by what is discussed in this summary, help and support is available from Samaritans by calling 116 123, emailing jo@samaritans.org, or visiting samaritans.org

Note:  this summary is provided to assist in understanding the determination.  It does not form part of the reasons for it.  The full determination, which is available on the Scottish Courts and Tribunals website,  is the only authoritative document.

Introduction

Sheriff Simon Collins KC has issued his determination following a Fatal Accident Inquiry into the deaths by suicide of Katie Allan and William Brown, which occurred at HM Prison and Young Offenders Institution Polmont.

Katie, 21, was found dead in her cell on 4 June 2018.  William, 16, was found dead in his cell on 7 October 2018.  

The sheriff has found that there were reasonable precautions by which both deaths might realistically have been avoided, that there were systemic failures contributing to the deaths, and that there are other facts relevant to the deaths which it is appropriate to formally record. 

The sheriff has made a total of 25 recommendations which might realistically prevent other deaths in similar circumstances.

Background

 
Katie

Katie was a student at Glasgow University.  She had a positive background and supportive family [paras. 165 – 172].  But on 10 August 2017 she drove her car while under the influence of alcohol, lost control, mounted a pavement and struck a pedestrian. She later pled guilty to causing serious injury by dangerous driving and drink driving and, on 5 March 2018, was sentenced to 16 months’ detention [paras 173 – 175].

On admission (first to HMP Cornton Vale and shortly afterwards to Polmont), Katie was assessed under the Scottish Prison Service Talk to Me suicide prevention strategy (TTM).  She was not assessed as being at risk of suicide at that time, nor at any time prior to her death almost three months later [paras. 176 – 187]

Katie disclosed on admission that she had previously self-harmed, but the form recording that information was lost [paras. 177, 744], and this information was not recorded on a subsequent risk assessment as it should have been [paras. 182 – 184].  Healthcare staff were therefore aware of this information, but prison officers were not.

Katie had previously suffered from eczema and alopecia and these conditions began to present again in Polmont, the latter in particular causing her great distress.  The extent of this distress, although disclosed to healthcare staff, was not effectively shared with prison officers [paras. 197, 212, 217 – 226].

Although Katie was identified as having been bullied by another prisoner in April 2018, this was recorded in an intelligence log which was not accessible by frontline prison officers [paras. 209 – 210].   

Katie appealed against her sentence, but accepted legal advice to abandon the appeal at a hearing at the end of May 2018. This was stressful and upsetting for her as she had hoped the appeal might be successful [para. 234].  However, she would likely have been released on home detention curfew in early July 2018 in any event [paras. 205, 237].

On the days prior to her death in June 2018 Katie was subjected to further bullying and abuse.  She was distressed by this and reported it to her family during a visit on 3 June 2018. This was passed on to SPS staff but not properly recorded [paras. 242, 244 – 254].

In the early morning of 4 June 2018 Katie was found hanging in her cell. She had used the belt from her dressing gown to suspend herself from a rectangular metal toilet cubicle door-stop.   She had self-harmed by cutting herself shortly prior to her death.   She left a suicide note in which she expressed distress at the abuse which she had received, her sense of personal failure, and her fear of going home [paras. 256 – 269, 272, 289 - 290].

William

William was exposed to domestic violence, and drug and alcohol misuse from a very young age. He spent most of his short life in care, with numerous different foster parents, in a kinship arrangement with his paternal grandfather, and in several specialist residential and/or secure units. His mother, sister and half-sister are all deceased [paras. 291 – 296].

Prior to being taken into custody, William had self-harmed and made threats of self-harm and suicide on multiple occasions [paras. 297 – 320].

On 3 October 2018, William walked into a Glasgow police station with a knife. He was arrested and charged.  His position was that his actions were, in effect, a cry for help.  He was already on deferred sentence for other offences.  A social care officer who met with him was concerned that he was a suicide risk [paras. 321 – 325, 411].

William appeared at Glasgow Sheriff Court on 4 October, bail was opposed, and he was remanded in custody. No beds were available at secure units so he was taken to Polmont [paras. 328 – 339].

While in the custody of G4S prior to arriving at Polmont, he was documented as being a suicide risk, and was subject to high supervision and constant observation [para 343].  A social work vulnerable prisoner report was provided to Polmont staff, which set out that William was a looked-after/accommodated child.  It advised that, after being remanded, William had indicated that he was not suicidal, but ‘doesn’t know how he will be later when locked up’ [para. 344].  The Crown Office and Procurator Fiscal Service also faxed Polmont to notify staff that William should be considered a suicide risk [para. 345].

On admission, William was put on TTM with a requirement that he be subject to 30-minute observations, but was accommodated in a standard cell which contained a double bunk bed [paras.  347 – 362].

Following a case conference the next morning, 5 October 2018, the decision was taken to remove William from TTM. William’s denial that he was suicidal was accepted.  This was notwithstanding the documents stating that he was a suicide risk, and the absence of any other background information about him [paras. 376 – 383].

In the course of the morning further information underlining William’s risk of suicide was provided to SPS and healthcare staff at Polmont by his social worker, his support worker, and by William himself.  This was not shared nor acted upon.  William was not reassessed nor put back on TTM [paras. 371 – 372, 387 – 399].

William was found hanged in his cell on the morning of 7 October 2018. He had used a torn bedsheet to hang himself from the double bunk bed [paras. 404 – 411, 424 – 426].

Suicide in Scottish prisons

More than 100 prisoners in Scottish prisons have died by suicide since 2011.  Ten of these have been young prisoners in Polmont.  Most were not subject to suicide prevention measures at the time, although many previously had been. 

This indicates a suicide rate much greater than that for the general population, particularly as regards young prisoners.  The first days in custody are recognised as being particularly critical as regards suicide risk. 

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. 

More than 90% of Scottish prisoner suicides are by self-ligature (hanging).  Around 50% involve the use of ripped bedding materials as a ligature, and almost 10% involve the use of a belt. 

Existing prison suicide prevention policies and practices based on person-centred risk assessment have not been sufficient to reduce the suicide rate, particularly among younger prisoners [paras. 427 - 447].

Reasonable precautions

Katie

The sheriff found that there were multiple failures by prison and healthcare staff to properly identify, record and share information relevant to Katie’s risk in accordance with TTM.  However, it was not established that, but for these failures, her death might realistically have been avoided.  Even with the benefit of hindsight, Katie’s death was spontaneous and unpredictable.  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. 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 [paras. 668 – 728].

However, the sheriff found that it would have been a reasonable precaution to accommodate Katie in a cell without a rectangular toilet cubicle door-stop.  This item had long been known to be an obvious potential ligature anchor point, and could have been removed and replaced without significant cost.  Had it been, the death which Katie suffered would not have occurred [paras. 729 – 736].

William

The sheriff found that William’s death resulted from a catalogue of individual and collective failures by SPS and healthcare staff in Polmont.  Almost all of those who interacted with him were at fault to some extent [para. 765].

Reasonable precautions would have been for the case conference to have kept William on TTM [paras. 764 – 781], 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 [paras. 782 – 799].

Another reasonable precaution would have been not to accommodate William in a cell on his own with a double bunk bed.  This was well known to be a ligature anchor point risk.  Another young prisoner had hanged themselves from such a bunk bed in Polmont four years earlier.  Double bunk beds could have been removed and replaced without significant cost.  Alternatively, William could have been accommodated in a cell without a bunk bed in it.  Had either been done, the death which he suffered would not have occurred [paras. 801 – 807].

Defects in systems of working

Katie

The defect in the system of working which contributed to Katie’s death was that SPS had no system in place to regularly audit her cell for the presence of ligature anchor points, nor to remove or reduce such points as had been identified [paras. 738 – 742].

William

The same systemic defect was also present in William’s case [paras. 808 – 810].  Further defects contributing to his death existed in relation to:

(a) the system for providing Polmont with all the information relevant to suicide risk which had been available to the remanding court [paras. 811 – 817];

(b) the system within Polmont for sharing information from external agencies on the risk of suicide [paras. 818 - 823];

(c) Forth Valley Health Board’s system for actioning mental health referrals at Polmont [paras. 824 - 827]; and

(d) the system for assessing the risk of suicide under TTM, insofar as it permitted William to be removed from TTM in the absence of any background information about him or as to his risk of suicide [paras. 828 – 834].

Other facts relevant to the circumstances of the deaths

Katie

 Other facts relevant to Katie’s death, but which were not shown to have contributed to it, included:

(a) that the documentation relative to the TTM reception risk assessment carried out at HMP Cornton Vale was lost [paras. 743 - 746];

(b) that her history of self-harm was not recorded in the reception risk assessment at Polmont [paras. 747 - 749];

(c) that there were inaccuracies in the entries about Katie in the healthcare system used by medical staff [paras. 750 - 752];

(d) that there was a systemic failure by SPS staff in Polmont to use concern forms in accordance with TTM [paras. 753 - 755];

(e) that there was no single repository of information on Katie’s suicide risk accessible to staff [paras.  756 - 758]; and

(f) that the SPS/FVHB Death in Prison Learning Audit Review (DIPLAR) into Katie’s case did not consider the ligature and ligature anchor point which she used to die by suicide [paras. 759 - 761].

William

Other facts relevant to William’s death included:

(a) that William’s social worker was not contacted by the nurse carrying out his pre-case conference assessment [paras. 835 - 836];

(b) that William’s record of previous self-harm was not detailed in writing for all those who attended his case conference assessment [para. 837];

(c) that the case conference was not carried out in line with TTM in multiple respects [paras. 838 - 839]; and

(d) that, as in Katie’s case, the DIPLAR did not consider the ligature and ligature anchor point which William used to die by suicide [para. 840].

Recommendations

Recommendations have been made by the inquiry under the following headings.

Ligature prevention

The sheriff stressed the need for greater recognition by SPS of the importance of ligature prevention as an essential aspect of suicide prevention policy, and the need to commit to taking concrete and practical steps to address it.  Its failure to do so in the period since Katie and William’s deaths was criticised [paras. 842 – 855].  Accordingly the sheriff recommended:

(a) that SPS remove double bunk beds from all cells in any wing or hall in Polmont in which young prisoners are accommodated [paras. 856 - 857];

(b) that all rectangular toilet cubicle door-stops within Polmont be replaced with sloping door-stops or an equivalent anti-ligature design [paras. 858 - 862]; and

(c) that SPS should take steps to make standard cells at Polmont safer by identifying and removing, so far as reasonably practicable, ligature anchor points. This should include the creation of a toolkit to identify such anchor points, the carrying out of an audit using this toolkit, and a programme for their removal or replacement [paras. 863 – 868].  

Suicide prevention technology

Suicide prevention technology (‘signs of life’) is already in use in secure mental health settings and is being developed for possible use in prison estates in Scotland and elsewhere [paras. 536 – 543].  If viable, such technology has obvious potential for complementing existing suicide prevention policies. The sheriff recommended that SPS should actively pilot and review use of such technology in Polmont and report its findings to the Scottish Ministers within 12 months [paras. 869 – 872].

Ligature items

The sheriff recommended that SPS should review and revise its policy on permitting young prisoners to routinely have items readily capable of being used as ligatures, such as belts and dressing gown cords. The new policy should contain a presumption against possession of such items. The Prison Rules should be amended accordingly [paras. 873 – 882].

SPS should also undertake or commission research into the availability of alternative bedding materials for use by young prisoners in Polmont, looking at the potential for use of rip-resistant materials [paras 883 – 886].

Information sharing and recording

Under this heading the sheriff recommended:

(a) that Scottish Ministers should put a system in place which ensures that all written information and documentation available to a court when a young person is sent to custody is passed to SPS at the time of their admission. This should include any Criminal Justice Social Work Report or other reports by healthcare services or third-sector agencies [paras. 887 – 889];

(b) that SPS should introduce a secure electronic portal which will allow external agencies to provide information relevant to a prisoner’s suicide risk directly to Polmont, and put in place a system to ensure that such information is immediately acted upon and recorded [paras. 890 – 892];

(c) that 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 [paras. 893 – 894];

(d) that SPS should introduce a system whereby any bullying concerns relating to a young prisoner are promptly and proactively shared with the FLM of the hall where the prisoner is located and the staff having contact with them [paras. 895 – 896];

(e) that SPS and Forth Valley Health Board should review their training and guidance on the sharing of information relating to young prisoners to ensure that prison officers and healthcare staff are aware of all relevant issues [paras. 897 – 900];

(f) that 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 [paras. 901 - 904]; and

(g) that Forth Valley Health Board should provide further training to staff within Polmont on the importance of accurate record keeping [paras. 905 - 908].

Talk To Me Suicide Prevention Strategy

TTM is currently under review by SPS.  The inquiry recommends that it should be extensively revised.  The sheriff 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.  Accordingly:

(a) There should be a presumption that all young prisoners admitted to Polmont will be subject to TTM for a minimum of 72 hours following admission, and not removed from it until a case conference has so decided [paras. 911 - 919];

(b) All TTM risk assessment forms should be amended so as to contain a guided process for the assessor including prompts, checklists, and questions to better identify, assess and record the prisoner’s suicide risk and protective factors at the time of assessment; and to facilitate ongoing assessment thereafter [paras. 920 – 922];

(c) TTM forms should contain a guided process for the assessor in relation to care planning for a prisoner being made subject to TTM.  This should include specific prompts, checklists, and questions to assist in grading the level of risk presented and deciding on appropriate protective measures [paras 923 – 926];

(d)  There should be specific guidance to prison staff in relation to obtaining background information relative to a young prisoner’s suicide risk on admission.  Pending receipt of such information, the default position should be that the prisoner will be subject to TTM [paras. 927 – 929];

(e) TTM guidance as regards risk assessment should be amended so as to better emphasise the importance of reduction of the risk of self‑ligature in the context of suicide prevention, and should include assessment of the ligature anchor point risk within the prisoner’s cell [paras. 930 - 933];

(f) TTM guidance as regards ongoing risk assessment should better emphasise (i) the importance of obtaining background information in relation to a prisoner, (ii) identifying dynamic risk and protective factors, and (iii) not taking a prisoner’s self‑report and non‑verbal presentation as determinative.  Where a prisoner is observed to be in distress such as should trigger the completion of a concern form, all TTM documentation in relation to the prisoner should be reviewed [paras. 934 - 936];

(g) TTM should include periodic proactive reviews and evaluations of a prisoner’s suicide risk and protective factors in the light of all available information, at such frequency as may be determined on a case-by-case basis [paras. 937 - 939];

(h) SPS should develop a new system of recording issues of concern which relate to a prisoner’s suicide risk under TTM, so as to ensure that all relevant information in relation to such a risk is recorded in writing, collated in a single place, and is available to be periodically reviewed and assessed.  Pending this, SPS should issue further guidance and provide specific training on the importance and use of concern forms [paras. 940 - 944];

(i) SPS should develop a system of electronic recording for all TTM documentation, so as to ensure that all such documentation is not lost or mislaid, and is in any event readily accessible to frontline SPS staff [paras. 945 - 948];

(j) A transitional care plan should continue to be mandatory for all young people removed from TTM.  Specific guidance and training should be provided on the options available, which should emphasise the prevalence of suicide by persons who have previously been subject to TTM [paras. 949 - 954]; and

(k) TTM refresher training should be provided to all staff at a significantly greater frequency and/or duration than 2 hours every 3 years, the precise amount to be determined by the current TTM review [paras. 955 - 958]

Death in Prison Learning Audit Reviews

Where a prisoner has died from suicide, the sheriff recommends that the DIPLAR must consider the safety of the prisoner’s physical environment within Polmont and the means by which they were able to die by suicide [paras. 959 - 962].

Condolences

In common with the other participants, the sheriff offered his condolences to the families of Katie and William, and paid particular tribute to the contributions of Linda and Stuart Allan [para. 976].