The deaths of a young woman and a teenage boy while in custody at a young offenders’ institution in Scotland “might have been avoided”, an inquiry has found.

Katie Allan, 21, and William Brown, 16, took their own lives within months of each other at Polmont Young Offenders Institution in Falkirk in 2018.

A fatal accident inquiry (FAI) was held last year into the deaths.

In his determination, published on Friday, Sheriff Simon Collins said “systemic failures” contributed to their deaths and made 25 recommendations as part of efforts to “realistically prevent” other tragedies in similar circumstances.

University of Glasgow student Allan, 21, was found dead in her cell on 4 June 2018 while serving a 16-month sentence for drink-driving and causing serious injury by dangerous driving.

Brown, also known as William Lindsay, was found dead in his cell on 7 October 2018, three days after being admitted to Polmont as there was no space in a children’s secure unit, having walked into a police station with a knife.

‘Multiple failures by prison and healthcare staff’

Sheriff Collins singled out the Scottish Prison Service’s (SPS) Talk to Me (TTM) suicide prevention strategy.

He noted Ms Allan had been assessed but was not deemed to be at risk on her admission to custody – first to HMP Cornton Vale then Polmont – nor at any time prior to her death almost three months later.

However, he said that during her incarceration there was a “systemic failure” by prison staff to complete “concern forms” that could have triggered the TTM process, pointing to a number of incidents recorded by prison staff that should have been red flags.

These included Ms Allan being bullied by other prisoners, distress caused by hair loss resulting from alopecia, her distress at being strip-searched by prison staff, and the failure of her appeal against her conviction.

Her weight also dropped from 65kg to 58kg during her time at the facility, which Sheriff Collins said should have been a “cause for concern” by staff.

The sheriff found “multiple failures by prison and healthcare staff to properly identify, record and share information” relevant to Ms Allan’s risk in accordance with TTM.

‘A catalogue of individual and collective failures’

Mr Brown was placed on TTM on admission to Polmont only to be removed from it the next morning, despite presenting as a “very high risk” individual.

He was also not placed back on TTM when “further information” about his level of risk was provided to prison staff by a social worker later that day.

Sheriff Collins added: “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.”

‘A realistic possibility their deaths might have been avoided’

The sheriff also described as “defective” the systems for sharing information between the SPS and other bodies, including courts and external agencies, about prisoner risk.

He additionally found issues with the way risk assessment information was recorded on prison systems.

The sheriff said “reasonable precautions” could have been taken around the safety of cells which may also have helped to prevent the deaths.

Sheriff Collins stated: “Had Katie been put on TTM on the night of 3 to 4 June 2018, and had William not been removed from it prior to the night of 6 to 7 October 2018, there was a realistic possibility that their deaths might have been avoided.”

He added: “Had they been on TTM at these times, it is likely that they would have been, at the very least, subject to regular checks and observations within their cells, in particular overnight.

“The time available to them to die by suicide without being observed would therefore have been materially reduced.

“That does not mean that their deaths would necessarily have been avoided, or even that they would probably have been avoided. But I have no hesitation in accepting that there was at least a realistic possibility that they might have been.”

Raft of recommendations

The 25 recommendations included ligature prevention, such as removing double bunk beds from cells, and identifying and removing, so far as reasonably practicable, ligature anchor points.

In regards to information sharing and recording, the sheriff has called for Scottish ministers to put a system in place that ensures all documentation available to a court when a young person is sent to custody is passed to SPS at the time of their admission.

The sheriff said TTM, which is currently under review by the SPS, should also be extensively revised.

One of the recommendations included a presumption for all prisoners sent to Polmont to be subject to TTM for a minimum of 72 hours following admission, and not to be removed from it until a case conference has so decided.

‘These deaths should not have happened’

Justice Secretary Angela Constance said the deaths of Ms Allan and Mr Brown “should not have happened whilst they were in the care of the state”.

A spokesperson for the SPS added: “We are grateful to Sheriff Collins for his recommendations, which we will now carefully consider before responding further.”