Sheriff makes 25 recommendations after inquiry into two suicides in young offenders institution

About this case:

• Citation:
  [2025] FAI 6
• Judgment:
  External link
• Court:
  Sheriff Court
• Judge:
  Sheriff S G Collins

Katie Allan and William Brown, aged 21 and 16 respectively, both took their own lives by hanging whilst they were detained at the Polmont Young Offenders Institution in 2018. Whilst their deaths were not directly connected, the decision was taken to hold a single inquiry, it appearing to the Lord Advocate that their deaths occurred in similar circumstances.

The inquiry was conducted by Sheriff Simon Collins at Falkirk Sheriff Court, with the Crown represented by Ms Cross, Senior Advocate Depute, and Mr Halliday, advocate. Other parties represented included the SPS, the Scottish Prison Officers Association, and members of both families.

Factors not noted

Katie Allan pled guilty to causing serious injury by dangerous driving after she struck a pedestrian while driving home under the influence of alcohol in August 2017. Although she had no previous convictions and was noted to be highly remorseful, she was sentenced to 16 months’ detention, which distressed and shocked her.

Although SPS staff were aware of Katie’s history of self-harm, this information was not recorded and they did not seek any information in relation to her medical or mental health history from her family or NHS staff. However, as her sentence progressed her mental health began to deteriorate, as well as her alopecia returning. After a series of distressing events from 1 to 3 June 2018, she was found hanging from a metal toilet cubicle door stop in her cell on the morning of 4 June.

William Brown walked into a Glasgow police station carrying a knife on 3 October 2018, while on deferred sentence for other offences. A social care officer expressed concerns that he was a suicide risk, but as no beds were available in secure units he was taken to Polmont. On admission he was put on the Talk To Me programme with a requirement that he be subject to 30-minute observations, but he was accommodated in a standard cell containing a double bunk bed.

On 5 October, the decision was taken to remove William from TTM, notwithstanding the documentation that he was a suicide risk. He was not reassessed or put back on TTM even when further information underlining his risk of suicide was presented to SPS staff. He was found hanged in his cell on the morning of 7 October, having used a torn bedsheet to hang himself from the bunk bed.

The Crown submitted that although Katie clearly had difficulty adjusting to her time in custody, multiple factors recognised as suicide factors were not noted or picked up on by staff. Six reasonable precautions were suggested that, taken in cumulo, might have prevented her death, and separately it was submitted that the metal door stop could have been replaced with one that could not be used as an anchor point. In relation to William, defects in the TTM strategy, including its reliance on self-reporting, were identified, as well as systemic failures in the prison system in common with Katie’s case.

Known risk

In his decision, Sheriff Collins noted the unusual nature of the inquiry, saying: “Since 2010 more than ten children and young persons have died by suicide in Polmont, and more than a hundred prisoners have died by suicide across the whole Scottish prison estate. Each of these deaths will have generated a FAI. Yet seldom have such inquiries made significant findings in relation to precautions or defective systems of work, nor have they made substantial recommendations for a change of approach to suicide prevention”.

He continued: “Meantime deaths by suicide continue to occur in Scottish prisons, and at a rate which appears, as detailed below, to be markedly in excess both of the suicide rate in the Scottish population generally, and the suicide rate to be found in almost all other prison populations in Europe.”

In respect of Katie’s death, the sheriff said: “The simple fact is that none of the many people who gave evidence in relation to their contact with Katie while she was in Polmont thought that she was at risk of suicide. Indeed, a theme which emerged from the witnesses’ evidence was to the effect that Katie was the last person whom they would have expected to take her own life.”

However, he continued: “In Katie’s case the death was suicide by self-ligature from the rectangular door stop in cell 1/33 on 3 June 2018. It would have been a reasonable precaution to have removed and replaced that door stop with an anti-ligature stop prior to this date, standing the known risk that it presented and the ease with which it could have been removed. Had this been done, the death which Katie suffered could not and would not have occurred.”

Individual and collective failures

Turning to William Brown, Sheriff Collins said: “William’s death resulted from a catalogue of individual and collective failures by prison and healthcare staff in Polmont. Almost all of those who interacted with him were at fault to some extent. Looked at broadly, and as SPS pithily submitted, the decision to put William on TTM following the RRA on 4 October 2018 was plainly correct, and the decision to remove him from TTM following the case conference on 5 October 2018 was plainly wrong.”

He added: “It would have been a reasonable precaution to have removed double bunk beds from use in relation to all single occupancy cells for young prisoners in Polmont prior to 2018. This could have been done relatively cheaply and easily, and did not require substantial capital expenditure. Had this precaution been taken, William could not have been accommodated in a cell with a double bunk bed at the time when he was, and so would have been unable to self-ligature as he did on the night of 6 - 7 October 2018.”

Sheriff Collins concluded: “In common with all the participants in the inquiry, I offer my condolences to the families of Katie and William. I would wish to particularly acknowledge the contributions of Linda and Stuart Allan, at least one of whom attended every day of the inquiry, and whose dignity and courage were evident throughout.”

The sheriff therefore concluded that both deaths could have been prevented by the taking of reasonable precautions, and made 25 recommendations, including in relation to the TTM programme, the training of SPS staff, and on ligature prevention in cells as an aspect of suicide prevention policy.