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 was a student at Glasgow University. She had a positive background and supportive family. 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.

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.

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.

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. However, she would likely have been released on home detention curfew in early July 2018 in any event.

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.

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.

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.

Prior to being taken into custody, William had self-harmed and made threats of self-harm and suicide on multiple occasions.

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.

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.

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. 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’. The Crown Office and Procurator Fiscal Service also faxed Polmont to notify staff that William should be considered a suicide risk.

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.

Reasonable precautions

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.

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.

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.

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.

Defects in systems of working

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.

The same systemic defect was also present in William’s case.

Recommendations

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. Accordingly the sheriff recommended, among other things:

1. that SPS remove double bunk beds from all cells in any wing or hall in Polmont in which young prisoners are accommodated;
2. that all rectangular toilet cubicle door-stops within Polmont be replaced with sloping door-stops or an equivalent anti-ligature design; and
3. 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.

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. 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.