Scottish Ministers & Scottish Prison Services Response

Form 6.2

RESPONSE

SHERIFFDOM OF TAYSIDE, CENTRAL AND FIFE at FALKIRK

Court ref: FAL-B118-23

DETERMINATION OF SHERIFF SG COLLINS KC

UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016

in the inquiry into the deaths of

KATIE ALLAN AND WILLIAM LINDSAY OR BROWN

To the Scottish Courts and Tribunals Service

1. The Scottish Ministers of which the Scottish Prison Service (SPS) is an executive agency, being the body to whom recommendations under section 26(1)(b) were addressed, do respond as follows.
2. The Scottish Ministers were a participant to the Inquiry. To reflect the Sheriff’s recommendations, and for clarity, the response refers to both Scottish Ministers and SPS.
3. SPS apologise to the families of Katie Allan and William Lindsay or Brown for their deaths in SPS care. SPS recognises that immediate action and systemic change needs to occur, driven by a commitment to learning from the deaths of Katie Allan and William Lindsay or Brown. Set out below is the SPS’ and Scottish Ministers’ response to Sheriff Collin’s recommendations which are all accepted in full. SPS acknowledges that the process of the Fatal Accident Inquiry revealed systems and processes which require overhaul. A range of action is underway, with some actions already in place, which will deliver system-wide improvement and enable enhanced support to the most vulnerable young people at one of the most challenging times of their lives. This includes an overhaul of the Talk to Me policy, a focus on ligature prevention across the estate and the implementation of a minimum of a 72-hour observation period for all young people on admission. SPS are committed to ensuring all young people in the estate are protected, supported and cared for while that work is underway.
4. SPS recognise the importance of each recommendation - it is a stark reminder of the responsibility we have for those in our care. The full response below, sets out actions taken and timescale for further action:
5. Recommendation 1– Double bunk beds should be removed from all cells in any wing or hall within Polmont in which young prisoners are accommodated. SPS must take all necessary measures to ensure that no young prisoner is in future accommodated on a single occupancy basis in a cell in which there is a double bunk bed.
6. Response – SPS understand the importance of the physical environment and action has been taken. SPS has now removed all bunk beds from accommodation within Polmont that a young prisoner (those aged between 18 and 21 years old) might be placed in. Furthermore, SPS has issued an instruction to all Governors in Charge throughout the estate that no young prisoners are to be accommodated on a single occupancy basis in a cell where there is a double bunk bed. While work to meet this recommendation is complete, work will remain ongoing on how improvements can be made to the physical environment to reduce the risk of harm.
7. Recommendation 2 - All door stops of the type identified in the book of photographs which forms Crown Production 92 (photographs 95 - 112), and which are of the same or equivalent design as the door stop used as a ligature anchor point by Katie, should be removed from all cells in Polmont and replaced with sloping door stops (such as that identified in the photograph in SPS Production 22/2), or an equivalent anti-ligature design.
8. Response – We acknowledge the ligature risk posed by rectangular door stops and therefore all rectangular door stops of the type identified in the book of photographs which forms Crown Production 92 (photographs 95 - 112), and those of the same or equivalent design which could be used as a ligature points have been removed. Door stops which remain are either sloping or positioned at the top of a door frame so cannot be used as a ligature point. SPS places safety and care at the core of the work programmes undertaken on the physical environment of cells to mitigate ligature risks.
9. Recommendation 3a - Develop a standardised toolkit for auditing cells for the presence of ligature anchor points. This toolkit should, in particular, (i) identify both obvious and potential ligature anchor points; (ii) specify whether such points are inherent to the design of fixtures or fittings within the cell, or due to modification of, or damage to, such fixtures and fittings; (iii) provide a system of grading the level of risk in relation to each identified ligature anchor point (for example, by reference to the ease/level of ingenuity required to use it for self-ligature), and so provide a system of grading the level of ligature anchor point risk in relation to the cell as a whole.
10. Response – Recognising the importance of this recommendation, SPS established a Ligature Toolkit Working Group as a priority in September 2024 which includes expertise from multiple SPS departments including Estates, Health and Wellbeing, Legal Services and Operations Directorate, to develop a Ligature Points Audit Tool specifically for use in Scottish Prisons. The group has completed preliminary work, which considered “off the shelf” ligature toolkits; the ‘Manchester’ toolkit, and has heard from NHS experts, referring to guidance produced by the Care Quality Commission Guidance (Nov 23) - Reducing harm from ligatures in mental health wards and wards for people with a learning disability. On the basis of this, SPS is developing a bespoke toolkit utilising the ‘Manchester model’ as a baseline. The toolkit will be subject to external and peer review, before it is implemented across the SPS estate. A training programme to support the implementation of the toolkit will be developed recognising the importance, not just of development, but of consistent delivery of measures for suicide prevention. This work forms part of a dedicated taskforce approach to managing changes necessitated by these recommendations. SPS is prioritising this work and expects to have a prototype by end of March 2025. SPS will then seek to promptly test the toolkit at Polmont, which will commence in the summer of 2025. SPS will report to Scottish Ministers on progress.
11. Recommendation 3b - Use the foregoing toolkit to conduct an audit of potential anchor ligature points within all standard cells. This should result in the production of a report detailing all obvious and potential ligature anchor points within each cell, identifying whether they are inherent to the fixtures and fittings within the cell or are due to modification or disrepair, and provide a grading of the risk for each identified ligature anchor point and for the cell as a whole.
12. Response – In Polmont, SPS has removed all bunk beds for young prisoners and have either removed or replaced rectangular doorstops with a sloping door stop, or they been repositioned to the top of the door frame. Recognising the need for ongoing assessment of ligature points, SPS has undertaken two recent full audits: (1) a review of all ligature points used and cross-referenced by establishments to identify potential trends and risk areas whether they are inherent to fixture and fittings or due to modification or disrepair; and (2) an audit of all in-cell doors (for toilets and showers) again to identify potential trends and risk areas.
13. Following the implementation of the SPS Ligature Points Audit Tool, this will be utilised on top of these audits to conduct a review of potential anchor ligature points within all standard cells across the SPS prison estate, starting with and prioritising Polmont which, in turn, will be used to produce a report and recommendations detailing all obvious and potential ligature anchor points within each cell. This will include a grading/assessment of the risk they present.
14. Recommendation 3c(i) – As regards any ligature anchor points arising from damage to or modification of fixtures or fittings, (a) repair or replace same so as to remove or at least reduce the risk of ligature arising therefrom as soon as practicable; and thereafter (b) institute a policy of regular ongoing cell audit using the said toolkit so as to promptly identify and repair or replace any further damage or modifications which have created further ligature anchor points.
15. Response – SPS is committed to ongoing audits of all cells with regards to ligature risk. The SPS Ligature Points Audit Tool will be utilised for this purpose across the SPS estate on an ongoing basis. Any ligature anchor points identified as arising from damage to or modification of fixtures or fittings through the audit process will be actioned as a priority to remove or reduce risks as soon as practicable.
16. Recommendation 3c(ii) – As regards any ligature anchor points arising from the inherent nature of fixtures or fittings, (a) develop and publish a plan for their phased removal, replacement or modification, again so as to remove or at least reduce the risk of ligature arising therefrom; (b) specify a timeframe over which this plan is to be implemented having due regard to available resources; (c) commence implementation, for example, beginning with removal, replacement or modification of those fixtures and fittings graded as presenting the highest level of risk pursuant to the said toolkit; and (d) publish annual reports of progress in implementation of the said plan.
17. Response – As detailed above, SPS intend to utilise the SPS Ligature Points Audit Tool to conduct an audit of potential anchor ligature points within all standard cells across the SPS prison estate, prioritising Polmont first, and to produce a report detailing all obvious and potential ligature anchor points identified within each cell, also including a grading/assessment of the risk they present. SPS will then develop a proposed plan for their phased removal, replacement or modification. The plan will seek to address those potential anchor ligature points graded as presenting with the highest level of risk in the first instance.
18. The plan will be referred to the Scottish Ministers and SPS will publish annual reports of progress against implementation of the plan. The reporting will conclude once remedial work is completed.
19. Recommendation 3d – Ensure that proposed fittings and fixtures in any new build or refurbished cells are audited using the said toolkit at the planning stage, and that any fittings or fixtures graded as presenting an inherent and significant risk of being used as ligature anchor points are not included within such cells when built or refurbished.
20. Response – New builds such as HMP & YOI Stirling and the Community Custody Units have been built with the best available advice on mitigations for ligature points, as is the planning for both HMPs Highland and Once the SPS Ligature Points Audit Tool is agreed and implemented, it will be utilised to audit proposed fittings and fixtures in any new build or refurbished cells at the planning stage and any fittings or fixtures graded as presenting an inherent and significant risk of being used as ligature anchor points will not be included within such cells when these are built or refurbished.
21. Recommendation 4 – SPS should actively pilot and review use of in cell “signs of life” suicide prevention/monitoring technology in Polmont. SPS should not confine this pilot and review to Safer Cells but should also consider its use in standard cells. SPS should report the findings of this pilot and review, and any recommendations arising therefrom, to Scottish Ministers, within 12 months of the date of publication of this determination.
22. Response – SPS acknowledge the lifesaving opportunities that developing suicide prevention/monitoring technology bring and have engaged with other jurisdictions and with companies in relation to products that could be utilised for passive monitoring of prisoners in SPS’ custody both in relation to new build prisons and the existing prison estate. Polmont will be utilised as one of the pilot sites for the testing of any suitable products identified and/or developed. This will be carefully considered and SPS will report to Scottish Ministers on progress and a full report will be submitted on the outcome of the pilot and recommendations by 17 January 2026.
23. Recommendation 5 – SPS should review and revise its policy regarding permitting young prisoners to routinely have possession of items which are readily capable of being used as ligatures without ingenuity or adaptation, in particular belts and dressing gown cords. The new policy should contain a presumption, as regards young prisoners in Polmont, that they are not permitted to have possession of such items. That presumption should only be overcome in limited circumstances, for example where a healthcare professional has certified in writing that the prisoner is not at risk of suicide and that there is therapeutic reason for permitting them to have use of such items. The Prisons and Young Offenders Institution (Scotland) Rules 2011, SSI 2011/331 (as amended) (“the Prison Rules”) should be amended accordingly.
24. Response – As a priority, SPS will establish a short term working group to review all items young prisoners in Polmont are routinely permitted to have in their possession, to remove items which are readily capable of being used as ligatures without ingenuity or adaptation, including belts and dressing gown cords. This includes items provided by SPS (i.e. prison clothing, bedding etc.). This will include a review of those items that young prisoners are permitted to purchase from within and outwith the prison in terms of Rule 45 (Privileges) of the Prisons and Young Offenders Institution (Scotland) Rules 2011, those items that families and friends are permitted to send in, and any items or clothing that prisoners have in their possession when they are admitted to custody. The review will also consider whether it is practical to include a mechanism that would permit the presumption to be overcome in limited circumstances. SPS anticipate completing this work by the end of 2025. Thereafter a revised policy will be drawn up and implemented; where necessary the 2011 Rules will be amended to accommodate or provide for that policy. SPS will report to Scottish Ministers on progress on the review. The group will provide an update on scope and proposed timescales to the Cabinet Secretary by end of summer 2025.
25. Recommendation 6 – SPS should undertake or commission a research project in relation to the availability and cost of alternative bedding materials for use in cells by young prisoners in Polmont. This should determine whether there are bedding materials available which, even if not certified as anti-ligature and inappropriate for use in standard cells (such as Crown Production 38) are nevertheless rip-resistant, to the extent that they are significantly less amenable to being cut or torn by a prisoner so as to form a ligature than are the bedding materials currently in use. SPS should publish the findings of this research project and review its choice of bedding materials in standard cells at Polmont in the light of it.
26. Response – SPS understand the importance of carefully assessing all factors that may contribute to risk. SPS has commenced research in relation to the availability and cost of alternative bedding materials for use in cells by young prisoners in Polmont and will utilise the findings to inform its choice of bedding materials in standard cells at Polmont. The findings from the project will be published and SPS will consider on how best to balance safety with the needs and well-being of those in our care. An update to Ministers will be provided by end of summer 2025.
27. Recommendation 7 – The Scottish Ministers (“SM”) should put in place a system to ensure that all written information and documentation available to a court at time of remanding a young person, or sentencing them to custody, is passed to SPS with that young person on admission, whether physically or electronically, such that it can be considered when carrying out the RRA on that person. This should include, in particular, any written information or documents provided to the court by the young person or their representative, by social work or third sector agencies (including any criminal justice social work report (“CJSWR”)), and by health care services (including any mental health assessments carried out relative to the person’s fitness to appear in court).
28. Response – Scottish Ministers fully recognise the importance of ensuring that all relevant written information and documentation is available to the SPS when a young person is admitted, and they acknowledge that this did not happen. This reflects a broader systemic failure across agencies in terms of information sharing. To address this, the Scottish Ministers are convening a working group that will bring together representatives from criminal justice, health, social work, and third-sector agencies. The group will focus on determining the best way to ensure the timely and secure transfer of information from court to SPS, while fully complying with legal and data protection requirements. This will allow the information to be incorporated into the RRA completed by SPS when a young person is remanded or sentenced to SPS custody. The first meeting of this working group is scheduled for 24 March 2025, progress will be closely monitored and reported to the Cross-Portfolio Ministerial Group on Prisoner Health and Social Care.
29. SPS will actively contribute to the Scottish Government Working Group and understand the importance of lessons learned in information sharing and how this must be used in keeping young people safe. SPS agree that all available information should be provided by criminal justice partners who are part of the journey of custody at the time that a young person is being remanded or sentenced to SPS custody.
30. Recommendation 8 – SPS should introduce a secure electronic portal whereby social work, medical staff and third sector organisations can provide information relevant to a prisoner’s suicide risk directly to Polmont, and a system whereby any such information received will be immediately drawn to the attention of the first line manager (“FLM”) or nightshift manager of the hall where the prisoner is located, and recorded in a form which is readily accessible by SPS staff having contact with the prisoner.
31. Response – SPS is committed to developing and implementing a secure electronic portal whereby social work, medical staff and third sector organisations can provide information relevant to a prisoner’s suicide risk directly to Polmont, and which will alert the FLM or nightshift manager to any updates received via the portal. Due to the impacts of the Bail and Release from Custody (Scotland) Act 2023 and the Prisoners (Early Release) (Scotland) Act 2025 on SPS’ IT systems, which are being updated and tested during 2025, we expect it will be 2026 when SPS take this recommendation forward. In the meantime, communication has been issued to social work, medical staff and third sector organisations so they are clear how to directly provide information relevant to a prisoner’s suicide risk or any concerns with Polmont. Systems are in place in Polmont which alert the FLM or nightshift manager to any such information or concerns.
32. Recommendation 9 ––SPS should provide a dedicated 24-hour telephone number by which family members can call into Polmont in order to notify a concern relevant to suicide risk which they may have in relation to a prisoner. This phone number should be readily accessible on the SPS website, along with guidance as to its purpose and use. Where such a concern is received, an electronic concern form should be completed immediately, sent to the FLM or nightshift manager of the hall where the prisoner is located, and recorded in a form which is readily accessible by SPS staff having contact with the prisoner.
33. Response – In February 2024, SPS strengthened the ability to raise a concern by introducing a dedicated 24-hour telephone number for all prisons in Scotland. The concern line can be utilised by anyone to raise a concern about someone in SPS custody. The telephone numbers are readily available on the SPS website in the Family and Friends section – please see attached link Raise a concern | Scottish Prison Service. The webpage also details how to raise a concern about an individual’s mental health and wellbeing and what action SPS will take following receipt of such information.
34. SPS also issued staff with guidance in February 2024 with regards to the new processes for processing and recording a communication of concern received via the new phone lines. During normal working hours this information is required to be immediately relayed to the relevant FLM in the residential area where the individual resides. During patrol and nightshift periods the information is required to be immediately relayed to the Operations or Nightshift FLM. An electronic concern form will be completed and emailed to the FLM and copied to the establishment Duty Manager. Once actioned, the completed concern form will be uploaded to PR2 (SPS’ electronic prisoner record system) and located within the prisoner’s electronic record in a section that is readily accessible by SPS operational staff at the particular prison, who will have contact with the prisoner.
35. Recommendation 10 – SPS should introduce a system so as to ensure, except where there is an over-riding requirement in relation to prison security in a particular case, that where intelligence information is received suggesting that a young prisoner has been or is being bullied it (or at least the gist of it) is promptly and proactively shared with the FLM of the hall in which the prisoner is located, and with SPS staff having contact with them.
36. Response – SPS has established a short term working group to review Think Twice (The SPS Strategic Approach to Encouraging Respectful Behaviour in Prison). We recognise that the current policy has not worked and SPS will, as a priority, work to understand why this is the case and how we can ensure proactive sharing of information or intelligence. We will also aim to, with the support of external organisations who have expertise in anti-bullying strategies, work to develop a new strategy and reporting mechanism which delivers against the strategy’s aims. This will incorporate the above recommendations from Sheriff Collins. SPS anticipate completing this work during 2025.
37. Recommendation 11 –SPS and the FVHB should review their guidance in relation to sharing of information in relation to young prisoners in Polmont, and training in relation thereto, so as to ensure that both prison officers and health care staff are aware of all relevant issues which may affect a prisoner’s risk of suicide when assessing or reviewing his or her case.
38. Response – SPS will review with FVHB, as key partners, the guidance in relation to the sharing of information concerning young prisoners in Polmont, where it is appropriate to do so and there is a legislative basis that permits it. SPS are committed to revised guidance that will (while complying with rules on patient confidentiality and with professional duties of confidence), incorporate the above recommendations from Sheriff Collins seeking to improve how SPS staff share with NHS staff any relevant information it receives about any concerns regarding prisoners, including those raised by family, friends or through external criminal justice partners via the concern form process, or through its incident and intelligence reporting systems. The Cross Portfolio Ministerial Group on Prisoner Health and Social Care will receive regular updates to ensure that health-related recommendations are implemented.
39. Recommendation 14(i) – TTM guidance should be amended to emphasise the increased risk of suicide (a) within a prisoner’s first 72 hours in custody and (b) during the more restrictive regime in operation at weekends. TTM should provide as a default, and in the absence of exceptional circumstances to the contrary, that all young prisoners should be made subject to TTM for a minimum of 72 hours after admission to Polmont and not removed from TTM thereafter until and unless a case conference has so decided.
40. Response – SPS acknowledges and is prioritising robust and impactful suicide prevention measures. As a result, SPS will overhaul the Talk to Me policy. This will include measures to identify risk alongside a suite of relevant interventions. To ensure immediate action whilst this is in progress, in the interim from 13 March 2025 and until this has been completed, all young prisoners will be under observations from admission for their first 72 hours in custody and then until such time as a Case Conference assesses they have all suitable information to remove them from observation. To date, SPS has commenced a full-scale review of the TTM policy which included a range of evidence gathering including primary research with NHS staff and those in SPS care. SPS has appointed an independent expert to undertake the completion of the expert review, by the end of summer 2025. The output of that work will inform the next phase of the whole-scale review which will be completed by end of 2025. Following this SPS will commence implementation and training in 2026. SPS will report to Scottish Ministers on progress and will publish regular updates regarding the progress of the review of the Talk to Me policy.
41. SPS will incorporate the above recommendations from Sheriff Collins into the revised guidance documents.

Recommendations 14(ii) – 14(vii)

42. Recommendation 14(ii) – All TTM risk assessment forms should be amended so as to contain a guided process for the assessor. This should include specific prompts, checklists, and questions to be answered and recorded, so as to better enable (i) the identification, assessment and recording of the prisoner’s suicide risk and protective factors at the time of assessment; and (ii) ongoing assessment in the light of any changes in any of those factors thereafter.
43. Recommendation 14(iii) – Where a prisoner is assessed to be at risk of suicide, TTM initiation forms should be amended as to 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 be answered and recorded, so as to better enable the initiating member of staff to grade the level of risk presented and so put in place protective measures for the prisoner which are sufficient and proportionate to it.
44. Recommendation 14(iv) – TTM should contain specific guidance to prison staff in relation to obtaining background information relative to a prisoner’s suicide risk on admission, with express reference to the particular types of information which should be sought, when it is appropriate to obtain them, the process to be followed, and the person or persons who are responsible for doing so. In particular TTM should require staff to try to obtain background information relevant to suicide risk from the prisoner’s family, and from relevant health and social care agencies, (i) where the prisoner is young, (ii) it is their first time in prison, and/or (iii) there is evidence which may suggest a history of self-harm or suicide attempts. In such circumstances, and pending receipt of such information, the default position should be that the prisoner is made - or should continue to be - subject to TTM.
45. Recommendation 14(v) – 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. All risk assessment forms should be amended to require the assessor to consider the cell environment in which the prisoner is (or is to be) accommodated, and to assess the ligature anchor point risk within that particular cell as part of the overall risk assessment.
46. Recommendation 14(vi) – TTM guidance as regards ongoing risk assessment should be amended so as to better emphasise (i) the importance of obtaining background information in relation to a prisoner, (ii) identifying dynamic risk and protective factors in relation to the particular prisoner, and (iii) that a prisoner’s self-report and non-verbal presentation in relation to a risk of suicide should not be taken as determinative, but must be considered in the light of such information. Where a prisoner is observed to be in distress such as should trigger the completion of a concern form, guidance should place a requirement on the officer concerned to review all TTM documentation in relation to the prisoner.
47. Recommendation 14(vii) – In addition to the present system of suicide risk assessment based on RRAs and reactive day to day assessment by prison officers, TTM should include periodic proactive reviews and evaluations of a prisoner’s suicide risk and protective factors in the light of all available information. This should include review of prisoners who are not currently subject to TTM and be at such frequency as may be determined on a case-by-case basis.
48. Response – We have grouped recommendations 14(ii) through 14(vii) for the purposes of responding. SPS acknowledges TTM should be the first and most important step in preventing suicide and recognises the critical role it plays in safeguarding those in our care. Its effectiveness is vital therefore SPS is currently overhauling its TTM policy and guidance and will incorporate the above recommendations from Sheriff Collins into the revised guidance documents. The expert review of TTM is currently scheduled to be concluded by the end of summer 2025. The output of that work will inform the next phase of the whole-scale review which will be completed by the end of 2025, to commence implementation and training in 2026 of the new policy.
49. Recommendation 14(viii)– 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 development of a new system of recording issues of concern, SPS should issue further guidance and provide specific training so as to clarify when a concern form should be completed by prison staff and its importance and purpose for TTM. This should emphasise: (i) that concern forms should be used where prison staff have witnessed a prisoner in distress, and are not only for use by external agencies or staff without regular access to prisoners; (ii) that a concern form should be completed even where it is not thought that the prisoner is at risk of suicide; and (iii) the importance of accurate and timeous record keeping in relation to concerns relevant to ongoing assessment of suicide risk.
50. Response – SPS is currently reviewing its TTM policy and guidance and will incorporate the above recommendations from Sheriff Collins into the revised guidance documents. The expert review of TTM is currently scheduled to be concluded by the end of summer 2025. The output of that work will inform the next phase of the whole-scale review which will be completed by the end of 2025, to commence implementation and training in 2026 of the new policy.
51. Separately, SPS issued further guidance to staff regarding the revised process for processing and recording a communication of concern from an external caller, which includes family, friends and other external criminal justice partners. In addition, SPS will issue further guidance to staff in relation to the use of concern forms to record any concerns they may have about a prisoner’s welfare or safety. Training on the use of concern forms will be considered as part of the TTM review.
52. Recommendation 14(ix) – SPS should develop a system of electronic recording for all TTM documentation, that is, relating to a prisoner’s suicide risk assessment, recorded concerns and reviews, so as to ensure that all such documentation is not lost or mislaid, and is in any event readily accessible to frontline SPS staff.
53. Response – SPS is committed to developing and implementing a system of electronic recording for all TTM documentation. Due to the impacts of the Bail and Release from Custody (Scotland) Act 2023 and the Prisoners (Early Release) (Scotland) Act 2025 on SPS’ IT systems, which are being updated and tested during 2025, it will be 2026 when SPS take this recommendation forward. In the meantime, the existing recording system will be reviewed and appropriate use of the system, and access to it by staff, reinforced.
54. Recommendation 14(x) – A transitional care plan should continue to be mandatory for all young people removed from TTM, so as to ensure appropriate supports and follow-up checks are in place, and that their cell environment is appropriate in relation to potential ligature anchor points. Specific guidance and training should be provided on the options available to staff when compiling a transitional care plan for a young prisoner, including referrals to the FVHB mental health team, other agency referrals, counselling/other supports, or chaplaincy visits. This guidance and training should emphasise the prevalence of suicide by persons who have previously been subject to TTM.
55. Response – As detailed in the recommendation above, a transitional care plan is already mandatory for all young prisoners who have been managed on TTM. As part of SPS’ review of the TTM policy, SPS will develop an awareness package specifically on Transitional Care Plans which will be included within the revised TTM training for all staff and partners who work in SPS sites with young prisoners.We will develop this in line with the completion of the TTM review and overhauled policy by the end of 2025.
56. Recommendation 14(xi) – 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. Training should place particular focus on ligature anchor point and ligature item risks, the importance of accurate record keeping, the importance of obtaining information from external agencies, how to properly conduct a case conference, the use of concern forms, and any changes implemented as a result of the ongoing TTM review and this inquiry.
57. Response – SPS recognises that training is fundamental to the successful implementation of policies, ensuring that all staff are equipped with the knowledge and skills necessary to effectively support and safeguard those in our care. As part of the TTM review, SPS will consider the nature and frequency of training which will form part of the review. SPS is committed to increasing the frequency and duration of training and incorporating into the training a focus on ligature anchor points and ligature item risks, the importance of accurate record keeping, the importance of obtaining information from external agencies, how to properly conduct a case conference and the use of concern forms.
58. Recommendation 15 – Where a prisoner has died by suicide, the DIPLAR process must consider, and if so advised, make recommendations, in relation to the safety of their physical environment with Polmont and the means by which they were able to complete suicide. Where suicide has been by self-ligature, the DIPLAR process must consider the ligature anchor point risk of the cell or other place in which the death by suicide took place, and the nature and availability of the item used as a ligature.
59. Response –Although there have been improvements in the DIPLAR process over recent years, SPS recognises the need for continual improvement which is driven by lessons learned and systemic change. SPS has reviewed and implemented revised DIPLAR paperwork and guidance in October 2024 which requires staff to include details of the environment in cases where the death was suicide by ligature, including recording the fixture point and ligature used. They are also now required as part of the DIPLAR process, to consider and where appropriate, make recommendations, in relation to the safety and condition of the physical environment, the means by which a person dies by suicide and if by ligature the nature and availability of the item used.

Concluding Comments

60. SPS know that the deaths of Katie Allan and William Lindsay or Brown serve as a stark reminder of the responsibility to ensure the safety and wellbeing of those in SPS care.
61. The action(s) set out against each of the recommendations have been carefully considered and it is essential we take meaningful action to deliver the recommendations in full, improve our policies and practice and prevent such tragedies in the future. This includes strengthening safeguards, ensuring access to Mental Health support, ensuring staff are equipped to identify and respond to those at risk and foster an environment where individuals feel heard, supported and protected.
62. SPS recognise the pain and loss experienced by families, friends and all of those affected by William and Katie’s death and reiterate their deepest and sincere condolences. SPS recognise no words can undo this loss and are dedicated to ensuring lessons learned lead to actions which are real and result in lasting improvements.

Scottish Ministers

March 2025

Forth Valley Health Board Response

SHERIFFDOM OF TAYSIDE, CENTRAL AND FIFE AT FALKIRK
Court ref: FAL-B118-23

RESPONSE
on behalf of Forth Valley Health Board to the
Determination by Sheriff S.G. Collins KC in the
Inquiry into the deaths of Katie Allan and William Lindsay or Brown
under the Inquiries into Fatal Accidents and Sudden Deaths etc (Scotland) Act 2016

To: The Scottish Courts and Tribunals Service

Forth Valley Health Board, being a body to whom recommendations under section 26(1)(b) was addressed, do respond as follows.

1. Recommendation 11: SPS and the FVHB should review their guidance in relation to sharing of information in relation to young prisoners in Polmont, and training in relation thereto, so as to ensure that both prison officers and health care staff are aware of all relevant issues which may affect a prisoner’s risk of suicide when assessing or reviewing his or her case.

2. Response to Recommendation 11: A review has been carried out by the National Prison Network, in which both FVHB and SPS have participated, in relation to the sharing of information about young prisoners in HMP&YOI Polmont. A revised information sharing protocol is expected to be finalised shortly. FVHB are committed to sharing relevant information with SPS staff, having regard to the duties incumbent upon healthcare staff in relation to patient confidentiality. Healthcare staff understand that they are able to share necessary confidential information with SPS colleagues where that is indicated (for example, where there is risk to the patient.) The information sharing protocol is supplemented by “healthcare markers”, which are prepared by healthcare staff and put onto PR2. FVHB participate in Multi Disciplinary Mental Health Team meetings, which are held fortnightly and are chaired by the Deputy Governor. These meetings allow multi-agency discussions and reviews of prisoners at high risk.

3. All members of FVHB staff receive mandatory annual training on information governance requirements, which supports appropriate information sharing. Information sharing and Professional Boundaries training is also included as part of induction training.
4. A Mental Health Competency Framework was developed in 2019, and updated in May 2020, which all registered mental health nurses must complete. The Framework includes guidance on information sharing. Further detail on the Framework is provided in paragraph 15 below.

5. FVHB is committed to ensuring that any information passed to health care staff by SPS colleagues is recorded in the patient’s Vision records. Accordingly, the daily handover sheet will be updated to include this requirement and it will also be added to supervision guidance to remind staff of the need to include such information on Vision.

6. Recommendation 12: FVHB should implement a system for ensuring that referrals received by the mental health team in Polmont are immediately passed to and reviewed by a mental health nurse and, where necessary, acted on without delay. Written instruction and guidance for relevant staff should be produced, and if necessary, training given thereon.

7. Response to Recommendation 12: A review of the system for mental health referrals has been carried out. A Standard Operating Procedure (“SOP”) for the triage of mental health referrals was implemented on 19 June 2023 and was reviewed on 29 October 2024. The SOP has been shared with all health care staff at HMP&YOI Polmont. A copy was emailed to all staff and has been discussed at staff handovers and at Team meetings.

8. Referrals to the Mental Health Team are collected from the prison hall daily, Monday to Friday, and are triaged by a band 6 registered mental health nurse in line with criteria specified in the SOP. The mental health nurse will review the referral and the patient’s medical records to determine whether the referral is urgent or routine. Admin staff will then process the referral and add the patient to the urgent or routine mental health waiting list.

9. A band 6 mental health nurse is allocated to the referral waiting list each day and, based on criteria specified in the SOP, will select which patients need to be prioritised that day. In 2019, Care Partner, an electronic record system, was introduced. Care Partner supports specific mental health risk assessment and care planning documentation and allows for a standardised approach. The band 6 nurse will carry out a triage assessment on Care Partner, which will include a documented risk assessment and care plan. Copies of both documents are then added to the patient’s Vision records to record that triage has been completed. The patient may then be referred for further review, onward referral or any other intervention that is required. A full assessment will be carried out and entered on Vision.

10. Urgent referrals are usually seen on the same day and are required to be seen within 48 hours. Urgent criteria includes those on Talk To Me (“TTM.”) Routine referrals should be seen within 7 days, and where that is not possible, the reason will be recorded. The Admin team are informed of who has been seen by the nursing team, and the Admin team then update the waiting list at the end of each day and distribute the list to the Mental Health Team, Team leader, Healthcare Manager and Lead Nurse.

11. An SOP is in place (reviewed in March 2025) to deal with reports of concern of suicide risk from external parties who have engaged in the community with individuals who are admitted to prison from court, either on remand or following conviction. Any such concerns can be reported to a designated email address at the HMP&YOI Polmont Criminal Desk. The email is then forwarded to the HMP&YOI Polmont Admin Team, the Healthcare Manager, the Mental Health Team Leader, the Primary Care Team Leader and the Mental Health Team. A mental health nurse is allocated to the role of “duty worker” each day and the duty worker is responsible for acknowledging receipt of the alert from the external party, for reviewing the prisoner’s admission records on Vision and taking any appropriate action. All recipients of the alert will be advised of the outcome. In the event that an email is not received from the duty worker advising of how the alert was managed, the Team Leaders or Healthcare Manager will seek confirmation that the prisoner review has been actioned.

12. Recommendation 13: FVHB should provide further training to staff working within Polmont on the importance of accurate record keeping, with particular reference to the VISION system.

13. Response to Recommendation 13: All nursing staff have been reminded of their duties to ensure accurate record keeping in line with the standards set out in the guidance issued by the Nursing and Midwifery Council (“NMC.”) The NMC Code, which sets out the professional standards of practice and behaviour for nurses, deals with record keeping in part 10, a copy of which has been shared with all staff. Staff have also been provided with a copy of the Royal College of Nursing information leaflet “Record Keeping: The Facts”, which sets out the key principles of record keeping.

14. Sessions on record keeping are being undertaken on a regular basis at team meetings and during 1:1 supervision sessions. All members of clinical staff have mandatory 1:1 supervision every 6 to 8 weeks, with each session lasting 1.5 to 2 hours. As part of this supervision session, the nurse’s line manager will review their caseload, which includes a review of five sets of case notes. Any issues with record keeping will be raised during the 1:1 session and will be followed up, if required.

15. The Mental Health Competency Framework referenced above, in paragraph 2, also covers record keeping. All members of nursing staff must complete the Competency Framework. In order to certify that the nurse has achieved all competencies, a trained assessor will be present for a minimum of ten assessments, following which they will review the nurse’s notes. The assessor confirms the nurse’s competency to undertake a comprehensive clinical history and assessment of patients and demonstrate and apply a systemic approach to documentation skills.

16. A general audit of medical records is undertaken on a monthly basis. Ten sets of case notes will be reviewed by a band 6 nurse using an agreed template. Results are fed back at staff handovers, staff meetings and, if relevant, with individual staff at 1:1 supervision sessions.

17. An audit of mental health care plans is undertaken monthly using the “Transforming Care at Bedside” toolkit developed by the Robert Wood Johnston Foundation and the Institute for Healthcare Improvement. The toolkit is designed to improve the quality and safety of patient care and the effectiveness of the care team. As above, results are communicated to staff at staff meetings and with individual staff at 1:1 sessions, if required.

18. External care assurance visits by the Lead Nurses from FVHB’s Practice Development Unit occur quarterly and includes examination of the quality of documentation and record keeping. A report is generated following each visit and is shared with senior professional leaders. An action plan is then developed for any areas where substantial assurance has not been achieved.

19. Recommendation 14(x): A transitional care plan should continue to be mandatory for all young people removed from TTM, so as to ensure appropriate supports and follow- up checks are in place, and that their cell environment is appropriate in relation to potential ligature anchor points. Specific guidance and training should be provided on the options available to staff when compiling a transitional care plan for a young prisoner, including referrals to the FVHB mental health team, other agency referrals, counselling/other supports, or chaplaincy visits. This guidance and training should emphasise the prevalence of suicide by persons who have previously been subject to TTM.

20. Response to Recommendation 14(x): FVHB staff will continue to develop transitional care plans, in collaboration with SPS, which are person centred and designed to support young people who have been on TTM. The need to do so is covered by the Mental Health Competency Framework referenced above.

21. When a patient is taken off TTM, a mental health nurse will meet with them within seven days and, if deemed necessary, the patient will continue to be supported by an identified mental health nurse.

22. The Lead Nurse for FVHB is undertaking awareness sessions with all Mental Health Teams in the three prisons within Forth Valley in relation to care plans, including TTM transitional care plans.

23. Transitional care plans are currently being reviewed as part of SPS’ review of TTM.