Wednesday, January 22nd, 2025
Determination issued into the death of William Brown at HMP YOI Polmont
Mark Stewart KC and Elaine Smith represented the father of the late William Brown in the fatal accident inquiry into the circumstances surrounding William Brown, Jnr’s, tragic death when he was aged just 16.
William was a vulnerable young man. He spent much of his childhood in care and was subject to compulsory supervision measures. William had support from various organisations including the Child and Adolescent Mental Health Services due to his report of suicidal ideation, low mood and social anxiety. William was known to be prone to dangerous spontaneous behaviour.
William was arrested on 3 October 2018. At that time, he was held in police custody and subject to continuous monitoring. He appeared at Glasgow Sheriff Court on 4 October 2018. Despite his vulnerabilities, it was decided that William would be processed through the court system rather than the children’s panel. His application for bail was opposed and refused. As no bed in a secure unit was available, William was remanded in HMP YOI Polmont for the first, and last, time.
On arrival at Polmont, William was assessed as requiring observations every 30 minutes under the SPS suicide prevention strategy, Talk to Me. It was noted by healthcare staff that William had a history of self-harm and anxiety. He was recorded as appearing very vulnerable and that concerns had been raised by court and social work. Evidence of William’s vulnerability and historical suicide risk were available to the Sheriff at Glasgow, but reports of the risk he posed himself and additional concerns intimated directly to the prison following his remand, were not passed to the relevant prison and healthcare staff responsible for assessing William’s suicide risk.
Around 14 hours after his admission to Polmont, William was assessed as no longer being at risk of suicide and was removed from Talk to Me (TTM). No account was taken of the timing of that decision – the prison was about to move to its weekend regime whereby prisoners would be confined to their cells for the vast majority of the day. William was found in his cell having died at some point between 6 October 2018 and 7 October 2018.
The inquiry called at Falkirk Sheriff Court before Sheriff Simon Collins KC. The inquiry found that William’s death resulted from a catalogue of individual and collective failures by SPS and healthcare staff at HMP YOI Polmont.
Several features of the Sheriff’s determination flow from lines of inquiry pursued by Mr Stewart KC including:
- That William could reasonably have been accommodated alone in a cell without a bunk bed.
- That there was no system in place to audit the physical environment William was placed in, despite him being assessed initially as at risk of suicide.
- That the system for sharing information with SPS by external agencies relevant to a risk of suicide of young prisoners remanded or sentenced straight from court was defective and resulted in pertinent information not accompanying William to HMP YOI Polmont.
- That the SPS suicide prevention scheme TTM was defective in that it failed to require William to continue to be subject to TTM in absence of information relevant to his risk of suicide which was readily available from family, social work, mental health and third sector organisations.
- That too much deference was paid to an assessment of William made by a mental health nurse and too much weight was placed on William’s self-reporting.
In addition, a number of recommendations advocated for on behalf of Willian Brown Snr have been adopted:
- That the Scottish Ministers should put in place a system to ensure all written information and documentation available at the point of remanding a young person should be made available to Polmont.
- That the 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.
- That TTM should emphasise the increased risk of suicide during the more restrictive weekend regime.
- That TTM guidance should include a mandatory assessment of the cell environment in which a prisoner is to be accommodated.
- That relevant information should be available for periodic review and assessment.
A full copy of the determination can be found here.