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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.

HM Prison and Young Offenders Institution Polmont
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Polmont Young Offenders Institution

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’

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Undated file handout photo of Katie Allan. The Fatal Accident Inquiry into the deaths of Katie Allan and William Lindsay, who both took their own lives at Polmont Young Offenders Institution, begins today at Falkirk Sheriff Court. Issue date: Monday January 8, 2024.
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Ms Allan. Pic: PA

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’

  William Brown. Pic: Aamer Anwar & Co
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William Brown. Pic: Aamer Anwar & Co

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’

HMP and YOI Polmont

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

HMP and YOI Polmont

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.”

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Ex-classmates died after being treated at same mental health hospital – as concerns raised over more deaths

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Ex-classmates died after being treated at same mental health hospital - as concerns raised over more deaths

They were former classmates who both died after receiving care from the same mental health hospital three years apart.

Warning: This article contains reference to suicide

Multiple failings led to the death of 22-year-old Alice Figueiredo – who took her own life in July 2015 – and the NHS trust responsible for her care was charged with corporate manslaughter.

Last week, following a months-long trial, the trust was found not guilty of that charge but was convicted of serious health and safety failings.

Karis Braithwate, who had gone to school with Alice, also died in 2018, having been treated by the same NHS trust.

Reports seen by Sky News detail a decade of deaths at North East London NHS Foundation Trust (NELFT), with coroners repeatedly raising concerns about the mental health services provided by the trust – in particular at Goodmayes Hospital in Ilford.

Rushed assessments and neglect were often cited. One patient was marked as alive and well, even though he had taken his own life inside the hospital the previous day.

Another patient told staff he was hearing voices telling him to kill himself, yet staff did not remove crucial items from his possession – items he would later use to take his own life.

Karis, 24, was sent to Goodmayes Hospital after she tried to take her own life at a train station in October 2018. The next day, staff spent 27 minutes assessing her and a further two minutes confirming their conclusion.

Alice (left) and Karis (right) were schoolmates
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Alice Figueiredo (L) and Karis Braithwaite (R) died in 2015 and 2018 respectively

She was discharged from hospital in the afternoon. She then went to a nearby railway station and took her own life. Her death came less than an hour after she had left the hospital.

Karis had been friends with Alice, her mother said. The pair had been classmates at the same school.

Karis told her mother she was upset at being put on the same ward where Alice had taken her own life three years earlier.

Her stepfather Mark Bambridge called Karis sweet and kind and said she often “struggled with life”. He felt relief when she was taken to hospital, saying: “She was in a place where she would be taken care of.”

Mark Bambridge said Karis was a sweet and kind girl
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Mark Bambridge said Karis was a sweet and kind girl

Karis’s mother – who asked not to be named – said her daughter confided in her about the neglect she endured at the hospital.

Karis told her mother that her carer would sleep when they were supposed to be watching over her and said she never felt safe.

“She spoke of her belongings going missing, of being treated with indifference and disrespect, and of staff who showed little concern for her wellbeing,” her mother said.

Karis’s mother said her daughter was failed by the hospital and the family was offered only a “hollow, superficial and indifferent ‘apology’ from the administration team of those who were meant to protect her”.

In the wake of the verdict in Alice’s case, Karis’s mother said: “I am holding Alice’s family in my thoughts and praying they receive the justice they – and we – so clearly need and deserve.”

A spokesperson for NELFT called Karis’s death a “profound tragedy” and said the trust had conducted an in-depth review of patient safety since 2018, “resulting in significant changes in the way we assess risk of suicide”.

Goodmayes Hospital, and the NELFT, has been at the centre of a lengthy court battle

“We train our staff to consider the trauma in a patient’s history, rather than focusing solely on their current crisis,” the spokesperson added.

“This approach allows us to see the person behind the diagnosis, making it easier to identify warning signs and support safe recovery.”

The trust said it had also improved record-keeping and communication between emergency workers and mental health practitioners.

The man marked as alive after he’d died

Sky News looked at more than 20 prevention of future death reports, which are written by a coroner to draw attention to a matter in which they think action could be taken to prevent future deaths.

Behind each report is a different person, but there are some strikingly similar themes – failure to carry out adequate risk assessments; issues sharing and recording information; neglect.

day 2

One report said staff at Goodmayes Hospital “panicked and did not follow policy” in the wake of a man’s death in 2021, instead writing that he was still alive when he had died the day before.

Speaking in response at the time, the trust said it had written a “detailed action plan” to address concerns raised.

Another report said one woman developed deep vein thrombosis after she was left to sit motionless in her room. She had not eaten or drunk anything in the two days before her death, and the trust was criticised for failing to record her food intake.

NHS manslaughter trial - day 2

Responding to the report at the time, the trust said it had implemented new policies to learn from her death.

Issues stretched beyond Goodmayes Hospital and spanned the entire NHS trust.

One man was not given any community support and overdosed after his access to medication was not limited.

Another man, a father of three, was detained under the Mental Health Act but released from Goodmayes after just a few hours. The 39-year-old was found dead two weeks later after being reported missing by his family.

At his inquest, a coroner raised concerns about the lack of a detailed assessment around him, with a junior doctor saying he was the only doctor available for 11 wards and 200 patients.

‘Don’t kill yourself on my shift’

It has been 10 years since Alice took her own life inside the walls of Goodmayes Hospital. But current patients say the issues haven’t gone away.

Teresa Whitbread said her 18-year-old granddaughter Chantelle was a high suicide risk but she still managed to escape from the hospital “20 times”.

“I walked in one day and said, ‘Where is Chantelle?’, and no one could tell me,” she told Sky News.

Teresa Whitbread has begged social services to not let her granddaughter be returned to Goodmayes
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Teresa Whitbread does not want her granddaughter to return to Goodmayes Hospital

On another occasion, Chantelle managed to get into the medical room and stabbed herself and a nurse with a needle.

She said one nurse told her granddaughter: “Don’t kill yourself on my shift. Wait until you go home and kill yourself.”

Teresa grew emotional as she talked about her granddaughter, once a vibrant young girl and avid boxer, whose treatment is now managed by community services.

“It’s made her worse,” Teresa said of Chantelle’s experience at Goodmayes Hospital. “There’s no care, there’s no care plan, there’s no treatment.”

The NEFLT said it could not comment on specific cases but added that “patient safety is our absolute priority, and we work closely with our patients and their families to ensure we provide compassionate care tailored to their needs”.

Chantelle’s family say she is a shell of her former self and have begged mental health services not send her back to Goodmayes.

“Something has to change, and if it doesn’t change, [the hospital] needs to be closed down,” Teresa said.

“Because people are not safe in there.”

Anyone feeling emotionally distressed or suicidal can call Samaritans for help on 116 123 or email jo@samaritans.org in the UK. In the US, call the Samaritans branch in your area or 1 (800) 273-TALK

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MPs back legalising assisted dying in England and Wales after historic Commons vote

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MPs back legalising assisted dying in England and Wales after historic Commons vote

MPs have voted to approve a historic bill that would legalise assisted dying in England and Wales.

The Terminally Ill Adults (End of Life) Bill was approved by 314 votes to 291 at its third reading in the House of Commons – a majority of 23.

Politics Live: MPs back legalising assisted dying in historic Commons vote

Labour MP Kim Leadbeater, who proposed the legislation, was seen crying in the chamber as it went through.

Campaign group Dignity in Dying hailed the result as “a landmark moment for choice, compassion and dignity at the end of life”.

“MPs have listened to dying people, to bereaved families and to the public, and have voted decisively for the reform that our country needs and deserves,” said Sarah Wootton, its chief executive.

The bill will now go to the House of Lords, where it will face further scrutiny before becoming law.

Due to a four-year “backstop” added to the bill, it could be 2029 before assisted dying is actually offered, potentially coinciding with the end of this government’s parliament.

The bill would allow terminally ill adults with fewer than six months to live to apply for an assisted death, subject to approval by two doctors and a panel featuring a social worker, senior legal figure and psychiatrist.

Campaigners with Dignity in Dying protest in favour of the assisted dying Bill, in Parliament Square, central London, ahead of a debate on the Terminally Ill Adults (End of Life) Bill in the House of Commons. Picture date: Friday June 20, 2025. PA Photo. Photo credit should read: Yui Mok/PA Wire
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Campaigners with Dignity in Dying protest in favour of the assisted dying bill. Pic: PA

MPs have deliberated the proposals for months, with a vote in November passing with a bigger majority of 55.

Since then it has undergone some significant changes, the most controversial being the replacement of a High Court Judge’s approval with the expert panel.

Ms Leadbeater has always insisted her legislation would have the most robust safeguards of any assisted dying laws in the world.

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MP: ‘Surreal’ moment as assisted dying passes Commons

Opening the debate on Friday she said that opposing the bill “is not a neutral act. It is a vote for the status quo”.

She warned that if her plan was rejected, MPs would be asked to vote on it again in 10 years and “that fills me with despair”.

MPs have brought about historic societal change

A chain of events that started with the brutal murder of an MP almost 10 years ago has today led to historic societal change – the like of which many of us will never see again.

Assisted dying will be legalised in England and Wales. In four years’ time adults with six months or less to live and who can prove their mental capacity will be allowed to choose to die.

Kim Leadbeater, the MP who has made this possible, never held political aspirations. Previously a lecturer in health, Ms Leadbeater reluctantly stood for election after her sister Jo Cox was fatally stabbed and shot to death in a politically motivated attack in 2016.

And this is when, Ms Leadbeater says, she was forced to engage with the assisted dying debate. Because of the sheer volume of correspondence from constituents asking her to champion the cause.

Polls have consistently shown some 70% of people support assisted dying. And ultimately, it is this seismic shift in public opinion that has carried the vote. Britain now follows Canada, the USA, Belgium, Switzerland, the Netherlands and Australia. All countries with sophisticated health systems. Nowhere has assisted dying been reversed once introduced.

The relationship between doctor and patient will now also change. The question is being asked: Is an assisted death a treatment? There is no decisive answer. But it is a conversation that will now take place. The final answer could have significant consequences, especially in mental health settings.

There are still many unknowns. Who will be responsible for providing the service? The NHS? There is a strong emotional connection to the health service and many would oppose the move. But others will argue that patients trust the institution and would want to die in its arms.

The challenge for health leaders will be to try and reconcile the bitter divisions that now exist within the medical community. The Royal Colleges have tried to remain neutral on the issue, but continued to challenge Ms Leadbeater until the very end.

Their arguments of a failure of safeguards and scrutiny did not resonate with MPs. And nor did concerns over the further erosion of palliative care. Ms Leadbeater’s much-repeated insistence that “this is the most scrutinised legislation anywhere in the world” carried the most weight.

Her argument that patients should not have to fear prolonged, agonising deaths or plan trips to a Dignitas clinic to die scared and alone, or be forced to take their own lives and have their bodies discovered by sons, daughters, husbands and wives because they could not endure the pain any longer was compelling.

The country believed her.

The assisted dying debate was last heard in the Commons in 2015, when it was defeated by 330 votes to 118.

There have been calls for a change in the law for decades, with a campaign by broadcaster Dame Esther Rantzen giving the issue renewed attention in recent years.

Supporters have described the current law as not being fit for purpose, with desperate terminally ill people feeling the need to end their lives in secret or go abroad alone, for fear loved ones will be prosecuted for helping them.

Ahead of the vote, an hours-long emotionally charged debate heard MPs tell personal stories about their friends and family.

Maureen Burke, the Labour MP for Glasgow North East, spoke about how her terminally ill brother David was in so much pain from advanced pancreatic cancer that one of the last things he told her was that “if there was a pill that he could take to end his life, he would very much like to take that”.

She said she was “doing right by her brother” in voting for it.

How did MPs vote?

MPs were given a free vote, meaning they could vote with their conscience and not along party lines.

The division list shows Prime Minister Sir Keir Starmer voted in favour of the bill, but Conservative leader Kemi Badenoch voted against.

Health Secretary Wes Streeting and Justice Secretary Shabana Mahmood, who will have to deliver the bill, also voted no.

Read more: Find out how your MP voted

Bill ‘poorly drafted’

Opponents have raised both practical and ethical concerns, including that people could be coerced into seeking an assisted death and that the bill has been rushed through.

Veteran Labour MP Diane Abbott said she was not opposed to the principle of assisted dying but called the legislation “poorly drafted”.

Former foreign secretary James Cleverly echoed those concerns, saying he is “struck by the number of professional bodies which are neutral on the topic of assisted dying in general, but all are opposed to the provisions of this bill”.

Recently, the Royal College of Psychiatrists, the Royal College of Pathologists and the Royal College of Physicians have raised concerns about the bill, including that there is a shortage of staff to take part in assisted dying panels.

However, public support for a change in the law remains high, according to a YouGov poll published on the eve of the vote.

The survey of 2,003 adults in Great Britain suggested 73% of those asked last month were supportive of the bill, while the proportion of people who feel assisted dying should be legal in principle stood at 75%.

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How did your MP vote on the assisted dying bill?

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How did your MP vote on the assisted dying bill?

The assisted dying bill passed its third reading in the Commons with a majority of 23 and will now be passed to the House of Lords.

There were 314 votes in favour and 291 against.

In November, the bill passed its second reading by a majority of 55, more than twice as large as today. It then went to “committee stage”, during which the wording and implications were examined in detail, and tweaked with input from experts, stakeholders and the public.

Politics latest: Bill legalising assisted dying passed in the Commons

That amended bill will now be passed on to the House of Lords, where it will go through a similar process before being either passed back to the Commons with further amendments, or sent to the King for Royal Assent.

Only after both houses agree on the exact wording of the bill does it become law.

Who changed their vote since November?

A total of 56 MPs voted a different way today, compared to how they did in November. There were 11 who changed to yes, while 24 changed to no. There were also 21 MPs who voted last time who chose to abstain today.

Among those who chose to change their vote were foreign secretary David Lammy and culture secretary Lisa Nandy. Mr Lammy had voted against the bill in November, while Ms Nandy voted in favour. Both chose not to vote today.

Only one MP, Labour’s Jack Abbott, voted in favour today after voting against at the second reading.

Prime Minister Sir Keir Starmer has voted in favour of the bill on both occasions, as has Chancellor Rachel Reeves and former prime minister Rishi Sunak.

The health secretary, Wes Streeting, who will have a crucial role in implementing the legislation if it becomes law, has voted against the bill both times, as has Angela Rayner, the deputy prime minister, and opposition party leaders Kemi Badenoch and Nigel Farage.

Lib Dem leader Ed Davey voted against the second reading, but chose not to vote today.

The SNP again chose not to vote, as the bill will not apply to Scotland, but a majority of MSPs in the devolved Scottish parliament voted through similar proposals in its first stage last month.

They were among 43 MPs in total who did not vote this time, including the Speaker and his Deputies. That’s slightly lower than the 46 MPs who abstained during the second reading vote in November.

Overall, a clear majority of Labour MPs supported the bill, while most Conservatives voted against it.

What do the public think?

Pollsters YouGov asked people if they were in favour of assisted dying or against, before November’s second reading and again last month.

On both occasions, a majority said they approved of the policy becoming legal, both in principle and in practice.


The Data and Forensics team is a multi-skilled unit dedicated to providing transparent journalism from Sky News. We gather, analyse and visualise data to tell data-driven stories. We combine traditional reporting skills with advanced analysis of satellite images, social media and other open source information. Through multimedia storytelling we aim to better explain the world while also showing how our journalism is done.

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