It is six months since Scotland on Sunday highlighted the death of 16-year-old William Lindsay, who killed himself less than 48 hours after being remanded into Polmont Young Offenders’ Institution.
As those who have been following this story will know, William had spent most of his life in care, shunted from one home to another; and, to anyone with access to his history of self-harming, it would have been obvious he was a danger to himself.
William’s was just one of 34 suicides in Scottish prisons between 2016 and 2018. Only a few months earlier, 21-year-old Katie Allan had killed herself in the same jail. But I know – because I have been told many times – that the death of this particular teenager, with his boyish expression and flame-red hair, was the one that sent shock waves through the justice system.
It shocked the social workers who had been so intensively supporting William, and had flagged him up as a suicide risk. But it also shocked the prison officers responsible for his supervision; the Scottish Prison Service (SPS) which had faith in Talk to Me (TTM), its new anti-suicide strategy; and the Scottish government, which has staked its credibility on early intervention and a Whole Systems Approach aimed at keeping as many under-18s as possible out of custody.
The consequence of this consternation (and perhaps, more cynically, of the negative publicity) was that Justice Secretary Humza Yousaf ordered a review into mental health provision at Polmont.
This inquiry, carried out by HM Inspectorate of Prisons for Scotland (HMIPS) with the support of mental health experts, did not look directly at the suicides of Katie and William. But many of the issues it explored – information sharing, staff shortages, isolation, and the effectiveness of TTM – spoke directly to their deaths, particularly William’s.
The first thing to say about its report, published last week, is that it appears to be a rigorous piece of work. It includes a review of evidence on suicides in youth custody, carried out by the Scottish Centre for Criminal and Justice Research, as well as observations from inmates, their families, prison officers and NHS workers. And it makes 80 detailed recommendations.
The second thing is that some of its findings are deeply troubling. We have long been told Scotland’s suicide in custody rate is lower than most of its European counterparts, but the evidence review found it to be consistently higher than England and Wales; and it appears to be rising.
Further research revealed 59 per cent of the suicides in custody between 2016 and 2018 involved individuals who – like William – were on remand, while 41 per cent took place – like William’s – within the first four weeks of detention.
A staggering 71 per cent of the suicides involved prisoners who – like William – had previously been on TTM or its predecessor, and 25 per cent of all young people who were on TTM were – like William – assessed as no longer being at risk and taken off within three days.
With a depressing inevitability, one of the key failings identified involved “systemic inter-agency shortcomings” in the way information was shared. It was already obvious this applied to William. If the extent of his previous self-harming, and the report produced at his court hearing, had been passed on to all of those involved in his care at the point of his admission, perhaps the outcome would have been different.
But then “inter-agency shortcomings” are endemic. They have been a feature of almost every significant case review I have read. Caleb Ness, Liam Fee, Baby P – the list goes on. Every time you hope it will be the last; every time, you hope in vain. It is not surprising such shortcomings are as prevalent in prisons as in child protection.
Also predictable was the pressure on resources – the staff shortages leading to inadequate support and supervision, and the prioritising of dealing with crisis behaviours to the detriment of being able to deploy therapeutic interventions.
A lack of resources is likely to explain the difficulty remand prisoners face in accessing “purposeful activities and well-being opportunities” at Polmont, which in turn increases isolation.
But other failings are unfathomable. What are we to make, for instance of the revelation that Polmont – whose population is comprised of under-25s – has no NHS staff with training in adolescents?
While some of the report’s findings are straightforward indictments of the system, it also provides context, adding nuance, for example, to calls for greater use of safer cells and the removal of all ligature points. Safer cells – cells designed in such a way as to prevent suicide – can, it suggests, increase isolation and are seen by some as a punishment. Equally, the overuse of TTM may be as damaging as its under-use. It is important to understand that many decisions around suicide prevention are complex and taken against a backdrop of conflicting demands.
The report’s key recommendations include a reduction in social isolation, with a particular focus on those held on remand, and the development by NHS Forth Valley of a more strategic and systematic approach to prison healthcare. There is also a clear need for better information-sharing focused on well-being, with decisions taken on a multi-agency basis.
Of course, such recommendations are of value only if they are acted upon, which is a challenge at a time when budgets are stretched. While I have no reason to doubt the Scottish Government’s intentions, there are aspects of the review that give cause for concern. For example, it talks about the lack of an electronic platform for “rapid data transmission” to facilitate “effective information- sharing” at the “acute point of vulnerability” before going on to quote from a 2017 Scottish Parliament Health and Sport Committee report.
“The difficulties and dangers inherent in the lack of IT functionality have been known for many years,” the two-year-old report says. Sometimes reviews are a cover for inaction, rather than a catalyst for change. I hope this is not one of those occasions.
Even if every recommendation is implemented, overhauling Polmont is a damage limitation exercise. If children as vulnerable as William end up in jail, they have already been failed on multiple levels.
The Scottish Government is committed to reducing the number of young people in custody (and has done so quite effectively) yet, when William proved a danger to himself, there was nowhere else for him to go.
So, where is the review of the decision-making process that meant his case was heard in an adult court instead of through the Children’s Hearings System? Where is the scrutiny of a child protection system that allowed him to be moved 29 times in 14 years? And surely the report highlights the need for a more flexible approach to the provision of secure care.
Protecting prisoners in Polmont is crucial; of course it is. But Polmont is no place for anyone under the age of 18. The Holy Grail is to provide effective early intervention and diversionary schemes that prevent them from being there in the first place.