Fatal Accident Inquiries - prison custody deaths: Ministerial Accountability Board - final report

4. Background

4.1 Fatal Accident Inquiry findings.

4.1.1 Katie Allan and William Lindsay (or Brown)

Katie Allan died by suicide at HMP & YOI Polmont in June 2018. William Lindsay also died by suicide at HMP & YOI Polmont a few months later in October 2018. The joint FAI determination, issued by Sheriff Simon Collins KC on 17 January 2025^[3], concluded that significant environmental and systemic defects led to the preventable deaths of Katie and William. The determination was unprecedented in the number of recommendations made and it identified a catalogue of failures by the Scottish Prison Service (SPS) and the NHS, necessitating a significant programme of reform that Scottish Ministers accepted in full in March 2025.

The recommendations of the FAI determination covered themes including the prison cell environment, ligature risks, suicide prevention policies, information sharing between agencies, and staff training.

Systemic defects reported in the FAI included the absence of a system for regularly auditing the prison environment for potential ligature anchor points, nor a system to remove those identified. The determination noted that Katie's cell contained a metal toilet door stop despite this being recognised as a potential ligature point by SPS in preceding years. William was housed alone in a cell with a double bunk bed; double bunk beds, when located in single occupancy cells, were known by SPS to be a potential ligature anchor point. In both cases, the Sheriff noted that these fixtures could be used as anchor points without requiring ingenuity or adaptation.

Beyond physical environment flaws, significant failures were identified in the "Talk To Me" (TTM) suicide prevention policy and related information-sharing systems. The process for integrating vital risk information from external agencies such as social workers, health workers, and support workers was fundamentally flawed. In William’s case, because he was remanded straight from court, information that was relevant to his risk of suicide did not accompany him to HMP & YOI Polmont and was not readily available to prison staff following his admission.

Internally, there were multiple failures among prison and healthcare staff to properly record and share information relevant to Katie’s risk profile, including her history of self-harm and reported instances of bullying. Concern forms were not utilised correctly, and prison staff lacked a single, easily accessible source for all relevant risk information. These communication breakdowns extended to healthcare responses: a mental health referral for William was emailed, printed, and placed in a filing tray, remaining unactioned until after his death. Inaccurate records also led some medical professionals to wrongly assume Katie was already receiving formal mental health support.

These systemic issues culminated in poor risk management decisions. The system for assessing risk of suicide under TTM was found to be defective. Information relevant to his risk of suicide was not passed forward to the right people in the prison to be considered at his case conference. The DIPLAR (Death in Prison Learning and Audit Review) processes initiated after both deaths also failed to adequately consider or make recommendations in relation to the ligature anchor point, and the ligature used, to die by suicide.

4.1.2 Jack McKenzie

Jack McKenzie died by suicide at HMP & YOI Polmont in September 2021. The FAI determination was published on 20^th May 2025^[4] and concluded that SPS could have taken a reasonable precaution (removal or modification of the toilet cubicle door in Jack’s cell) that may have prevented Jack’s death and included 7 recommendations. Of these, three were identical in wording to recommendations made in Katie and William’s FAI, and four were new recommendations. The similar recommendations were around the auditing and removal of ligature anchor points in prison cells, and the new recommendations related to the Management of Offenders at Risk Due to Any Substance (MORS) policy and suicide risk, patrolling of residential halls, visual hatch checks to ensure people in custody are safe and well. The SPS response to the Jack McKenzie FAI was published in July 2025 and set out that most of the recommendations were accepted by SPS, with the exception of Recommendation 6 regarding the re-introduction of a late night hatch check noting this requires further exploration.^[5] The MAB agreed to include these recommendations in the scope of their oversight, given the similarities in the circumstances surrounding Katie, William and Jack’s deaths.

4.1.3 Sarah Jane Riley

Sarah Jane died by suicide at HMP Perth in January 2019. The FAI determination was published on 20th October 2025^[6] and found that while no formal precaution could be identified, systemic failings, particularly the lack of information sharing about Sarah Jane’s risk to herself, meant that had proper systems been in place her death could have been avoided. Sarah Jane was a transgender woman with a complex forensic history serving an Order for Lifelong Restriction (OLR). Sarah Jane was unlawfully held in segregation for 18 days prior to her death and had received an adverse Parole Board decision. The determination made 8 recommendations that call for stronger oversight, timely mental health and risk management interventions, improved information sharing, and clearer accountability to ensure the safety and lawful treatment of OLR and transgender prisoners.

The MAB considered Sarah Jane’s FAI determination at their meeting on 4 February 2026 and concluded the recommendations would not be formally included in the scope of the MAB. This was primarily due to the limited remaining time to meaningfully scrutinise progress. The MAB were significantly concerned with the findings of the Sarah Jane Riley FAI and agreed the broader systemic themes which align with those of the Katie, William and Jack FAIs would be addressed in this report under the section that highlights where the MAB feel further progress needs to be made. This includes the broader issue of progress on support for mental health and wellbeing for vulnerable individuals in custody and consideration of how people in custody can be supported to feel hopeful about the future.

4.2 Cabinet Secretary for Justice and Home Affairs Commitments.

The Cabinet Secretary for Justice and Home Affairs made additional commitments in response to the FAI, over and above the acceptance of all the FAI recommendations. In her ministerial statements in January^[7] and March 2025^[8], the Cabinet Secretary addressed the systemic failures identified by the determination, acknowledged that the deaths were preventable and committed to a systemic response aimed at action and lasting change.

Key commitments included:

• making immediate arrangements for non-means tested legal aid for bereaved families in FAIs;
• developing a new family advocacy and support service;
• seeking to lift the Scottish Prison Service's (SPS) corporate Crown immunity for which responsibility is reserved to the UK Government;
• commissioning an independent review of deaths in custody FAIs to focus on improvements relating to efficiency and effectiveness and trauma-informed processes;
• and the establishment of a National Oversight Mechanism, a national oversight body for all deaths in custody, independent from Government.

4.3 Alignment with previous reviews on Deaths in Custody

The FAIs referenced above, their recommendations and commitments made by Scottish Government sit within a broader landscape of work aimed at improving responses to deaths in custody. This includes significant reviews such as the “Independent Review of the Response to Deaths in Prison Custody” (2019–2021)^[9], jointly chaired by Wendy Sinclair-Gieben (former Chief Inspector of Her Majesty’s Prisons in Scotland), Professor Nancy Loucks (Chief Executive of Families Outside), and Judith Robertson (Chair of the Scottish Human Rights Commission). The recommendations from that review, alongside those contained in Sheriff Collins’ FAI determination, share areas of overlap and common themes. The establishment of the MAB does not replace the work required to progress outstanding recommendations from this or other reviews, but sought to keep attention on interconnected findings to inform systemic improvements, and support change across agencies to prevent future deaths in custody.