Jailed, Failed, Forgotten

Iwas​ on the ferry to Islay in November 2018 when I got a message telling me that a 16-year-old boy had killed himself in Polmont Young Offender Institution, which lies between Glasgow and Edinburgh. My contact had seen a newspaper column I’d written about the suicide a few months earlier of another prisoner at Polmont, a young woman called Katie Allan. I was working on a story about wild geese, which migrate from Greenland to Islay in their tens of thousands each year. They speckled the low-lying fields, but the dead boy was harder to trace. I sat for hours, sifting through Facebook accounts, until a second message told me he had swapped his father’s surname, Brown, for his mother’s, Lindsay. I typed in ‘William Lindsay’ and there he was: a boy in a EA7 bomber jacket with headphones round his neck, flaming hair and a lopsided smile.

When I got back to Glasgow, I learned why my contact had risked his job to give me the information. William had spent most of his life in the care of the state. His story was one of intergenerational trauma, common to many families in the West of Scotland, and of the lies Scotland tells itself about its treatment of its most vulnerable young people. William’s mother, Christine Lindsay, had been brought up by her grandparents, both of whom died before she was nineteen. She had one child, John, with her first partner; two, Robert and Shannon, with her second; and two more, Chloe and William, with her third. By the time William was born, Christine had endured beatings, depression and at least one suicide attempt. She drank heavily and abused amphetamines.

William was placed on the at-risk register soon after birth, and then taken into care. Between the ages of three and fifteen, he was moved between foster carers and children’s homes 27 times. In September 2017, he decided to move in with his family in Possilpark in Glasgow, one of most deprived areas in the country. After years of instability, he had a network around him: Christine, his sister Shannon and a team of social and support workers. He had his dog, Bear, and a job at a car wash. He loved computer games and rap music and trips into the countryside with Niall Cahill, from the charity Includem. ‘He was smart, generous and funny,’ Cahill told me, ‘but there was a dark side to him too.’ Like many teenagers, William sometimes drank too much and when he did, he tried to hurt himself. On one occasion, he took an overdose; on another, he wandered onto the railway tracks. There were reports of him zigzagging across the road in front of oncoming cars. During a spell in a secure unit, he placed a ligature around his neck.

William had been drinking on the night of Wednesday, 3 October 2018 when he walked into a police station carrying a knife, which he put on the reception desk. Those closest to him insist that he was looking for help. But it’s not surprising that the civilian worker behind the desk was alarmed. William was arrested, charged and held in police custody until he could attend court the following day.

His social workers put all their efforts into keeping him out of jail. In Scotland, most offences involving under-eighteens are dealt with through the Children’s Hearings System (CHS). Set up in 1971, it recognises that children who have suffered neglect or abuse often go on to offend. The focus is supposed to be on ‘needs’, not ‘deeds’. Children who have been referred to the CHS take part in a non-adversarial hearing before a lay panel charged with acting in their best interests. Scotland likes to see this system as evidence of its enlightened approach to youth justice, and as a model other countries, including England and Wales, would do well to emulate.

William was subject to a compulsory supervision order (an order issued to children who require extra protection). His alleged offence could have been handled by the CHS, as his social workers wanted. But the Crown Office and Procurator Fiscal Service (the equivalent of the Crown Prosecution Service) disagreed: carrying a weapon into a police station was a serious offence and the case must be heard in an adult court.

His social workers looked for a place in a secure unit in case it was decided he should be detained. There are four such units in Scotland, with a total of 78 beds. They are run by charitable organisations, but compete for business. To keep them viable, a proportion of their beds can be rented out to English local authorities. On the night William was arrested, every place appeared to be taken. When the order was given for detention, he was sent to Polmont. It was his first time in jail. ‘Secure units are warm places,’ a social worker told me:

They have carpets and drawings on the wall. The staff wear their own clothes and are not afraid to give new arrivals a hug. Polmont is grey and clinical. He would have been met and searched by uniformed officers … But it would have been walking into the wing that scared him most: the rows of cells, the clatter and – coming from Glasgow with its territorial warfare – the not knowing who else might be in there.

The court social worker had told the prison escort service about William’s recent history of self-harm, so he was monitored during the journey from Glasgow to Polmont. When he arrived he was placed on Talk to Me (TTM), a scheme for prisoners deemed at risk of suicide. Those perceived to be at highest risk should be assigned a ‘Safer Cell’ and checked every fifteen minutes. William was placed in a standard cell, with checks every thirty minutes. The next morning – Friday, 5 October – after a five-minute case conference, two prisoner officers and a mental health nurse decided he was no longer in need of extra surveillance. He was taken off TTM and observation.

Polmont wasn’t full, so many prisoners, including William, were placed alone in double cells with bunk beds. It was the start of the weekend – a difficult time for prisoners, who are locked in their cells between 4.30 p.m. on Friday and 7.30 a.m. on Monday. Polmont is notorious for its ‘window warriors’: young men who shout through the bars at night. William was bothered by the noise. At some point on Saturday or early Sunday, he wrote three long letters to his family. ‘It’s night-time now,’ he wrote. ‘I’ve only been in here for two sleeps.’ ‘Been crying a lot’; ‘Everyone’s terrorising me’; ‘Please help me.’ Then he hanged himself from the top bunk.

By the time I rang his mother’s doorbell, I had read the records on William kept by his social workers. They described foster carers who ‘could no longer manage [his] behaviour’ and children’s home staff who won his trust, then moved on. The saddest paragraphs were the ones that gave a glimpse of the boy he might have been. ‘When it was suggested to William [then aged ten] that he had the ability to attend mainstream education he was delighted,’ one entry read. ‘He began dressing in his school uniform and was not put off by comments from others.’ Another report recorded that he would trash his room and tamper with electrical sockets. At night, when he struggled to settle, he would revert to childhood habits, ‘singing nursery rhymes and stroking his hair until he fell asleep’.

Christine Lindsay didn’t want to talk to me at first. Her life was chaotic and I think she felt judged. A week later, she invited me back. Her house was tidy and she was wearing a pink blouse. A photograph of William in his burgundy blazer stood on the mantelpiece. His sister Chloe, then nineteen, had stopped by. Bear ran to the window and back again. Christine told me that Shannon – who had been heavily pregnant at William’s funeral – had given her baby the middle name Rose. She had placed a rose in William’s coffin. Christine gave me a copy of what she called ‘William’s story’, written on seven A4 sheets of paper in an erratic mix of capital and lower-case letters.

Christine is dead now; so is Shannon; so is Chloe. Shannon’s daughter is living with her father. I still have those sheets of paper. ‘William was all innocence, loved and respected,’ Christine wrote. ‘Twenty-seven times he was moved: I want answers.’

At least​ 51 prisoners aged 21 and under have died in Scottish jails since 1995. Sixteen of them (fourteen of whom died by suicide) were aged nineteen while thirteen were aged eighteen or under (all suicides). All but one of the suicides involved hanging. In Scotland, young offenders who aren’t on bail or in secure units are split between Polmont and Stirling (which replaced Cornton Vale in 2023 and only takes women prisoners), with the majority in Polmont. In England and Wales, young offenders are split between adult jails, Young Offender Institutions and Secure Training Centres. Since 1995, at least 296 prisoners aged 21 and under have died in England and Wales: 73 were nineteen (65 of them suicides); 56 were eighteen (55 suicides); 25 were between fifteen and seventeen (22 suicides). Overall, 88 per cent of the deaths were self-inflicted and, of those, 97 per cent involved hanging. The number of prisoners aged 21 and under who died in England and Wales is around six times that in Scotland, though its prison population is around ten times greater. In 2022, a Council of Europe survey of 48 member states found Scotland’s overall prison suicide rate (18.9 per 10,000) was 2.7 times higher than the average (7 per 10,000) and double that in England and Wales (9.3 per 10,000). In Scotland, as elsewhere, the majority of young people who take their own lives in jail do so within the first three months, with the first 72 hours the most critical.

The wellbeing of young offenders has never been a popular cause. Most of these deaths faded quickly from the headlines, if they made them at all. But in 2018, a collision of tragedies proved impossible to ignore. Four months before William Lindsay’s death, Katie Allan, a student at Glasgow University, had killed herself in Polmont. She was four years older than William and had pleaded guilty to causing injury by dangerous driving after knocking down a 15-year-old boy while over the limit. She had no previous convictions and was full of remorse. The victim’s parents had asked that she be given a non-custodial sentence, so it came as a shock when, on 5 March 2018, Sheriff David Pender jailed her for sixteen months.

Katie’s childhood had been as stable as William’s was volatile. She and her younger brother grew up in a semi-detached house on the southern edge of Glasgow, with their parents, Stuart, a data analyst, and Linda, a nurse turned government adviser. One cold November evening, I sat with Linda in a shelter at the top of her garden looking out towards Ben Lomond. She told me about her daughter, who loved her friends, her golden retriever, the Scottish band Skipinnish and family holidays in Arisaig, where she scoured the beach for cowrie shells. Katie spent the summer after school volunteering in Malawi. ‘We wanted our children to know they were privileged and not everyone had the life we had,’ Linda said.

In August 2017, after a night out with friends, Katie decided to drive home, clipped the central reservation and lost control of her car. Unaware she had hit anyone, she changed the tyre and drove on. Later that evening, a police officer knocked on her mother’s door and told her that someone driving a car registered to that address had left a boy lying unconscious on the pavement with a broken ankle and a fractured eye socket. Linda gave them the address of her daughter’s flat, and Katie was arrested. ‘From that day to the day she died,’ Linda told me, ‘her only concern was the damage she had caused.’

At first Katie tried to hide her distress from her parents, but she told the Glasgow University chaplain, Stuart MacQuarrie, who visited her in jail, that she had been strip-searched by prison officers and bullied by other prisoners. In exam years at school, Katie had suffered from eczema and alopecia, and had self-harmed. In Polmont, she lost weight, her eczema flared up, her mood dropped and her alopecia returned. In late May 2018, a month after her 21st birthday, she abandoned her appeal and shifted focus to the possibility of gaining early release with a home detention tag. But when her mother and brother visited Polmont on Sunday, 3 June, she was distraught. She told them there had been a big fight in the hall and she had been threatened. Linda alerted one of the prison officers. Someone spoke to Katie, but she wasn’t thought to be at risk of harming herself. At some point during the night, she hanged herself from a doorstop on her cell wall. A postmortem revealed self-harm marks on her arms and legs, and traces of the antidepressant mirtazapine, which she hadn’t been prescribed. Katie had been in Polmont one day short of three months.

The Allans broke the news to their son. They went to the mortuary to see Katie’s body. They went to Falkirk police station to read her suicide note. They also went to see Brenda Stewart, the governor of Polmont. ‘She didn’t know who was on duty that night,’ Linda told me. ‘She didn’t know if there was anything in Katie’s handover notes. She didn’t know she had been distressed. She knew nothing.’ The Allans had no intention of allowing their daughter’s suicide to be forgotten, however. They instructed Aamer Anwar, Scotland’s best-known human rights lawyer. In October, they held a press conference outlining the ways in which Katie had been failed and calling for reform of the Scottish Prison Service’s handling of mental health.

When Linda Allan told reporters that their ‘decision to speak to the press isn’t because we are so-called “middle class” nor because Katie was a woman, but … because this could happen to anyone irrespective of class, race, gender, sexual orientation or ability’, she didn’t know about William. But within weeks his death was all over the front pages. Soon Anwar was also representing Christine Lindsay and the then justice secretary, Humza Yousaf, had ordered an independent review into mental health provision at Polmont.

The review​ came to nothing, as did the other reviews that followed, including one looking into ligature anchor points in Polmont and another on the prison service’s ‘response to death in custody’. Last July, the Scottish Human Rights Commission criticised the ‘glacial pace’ of progress in tackling overcrowding, suicides and mental health problems in prisons, stressing that recommendations agreed decades ago had still not been implemented. The review into mental health provision at Polmont was led by Wendy Sinclair-Gieben, HM Chief Inspector of Prisons for Scotland. One of its key recommendations was a suicide prevention strategy for young people. The Scottish Prison Service dismissed the idea, opting instead to carry out an overarching review of Talk to Me. The review was never completed.

Meanwhile, the Allans and Christine Lindsay were doing battle with a recalcitrant judicial system. In Scotland, every death in custody is subject to a fatal accident inquiry, or FAI, the Scottish equivalent of an inquest. But before an inquiry can be held, the death has to be investigated by the police and the Crown Office and Procurator Fiscal Service. At first the COPFS said there was insufficient evidence to bring a prosecution in relation to Katie and William’s suicides. Only after the families exercised a Victims’ Right to Review (something few know they are entitled to) did it concede that there had been enough evidence to charge the prison service with breaches of the Health and Safety at Work Act. That hadn’t happened because, unlike the police and the NHS, state-run prisons across the UK have Crown immunity. Since 2011, the NHS has been responsible for delivering healthcare in Scottish prisons, so it might have been possible for the public prosecutor to bring charges against Forth Valley Health Board, but that hadn’t happened either. The best the families could hope for, they were told, was a Crown Censure – effectively a ticking off.

The Allans began to gather their own data. Alone at first, and then in collaboration with researchers at Glasgow University, they trawled through the records of hundreds of death-in-custody inquiries, and discovered not only a tendency to blame the offender, but also evidence of an insidious belief that such deaths were inevitable. Derek Livingston, the sheriff who presided over the inquiry into the death in 2017 of 19-year-old Liam Kerr, stated that ‘suicide is unfortunately something which occurs in the prison population and in particular the younger members of that group.’ Liam had been hearing voices and tried to kill himself hours after an NHS consultant had ruled out an immediate transfer to a psychiatric ward. He died a few days later in hospital.

‘An ungrievable life,’ Judith Butler has argued, ‘is one that cannot be mourned because it has never lived, that is, it has never counted as a life at all.’ Butler was talking about people on the ‘wrong’ side of a conflict, but the same applies to prisoners. Everything the Allans uncovered about deaths in custody showed that these lives didn’t count: the length of time families had to wait before inquiries took place; the complacency of the SPS; the lack of any meaningful subsequent action. The main purpose of an FAI is to establish whether death could have been prevented and to identify measures that could prevent future deaths, yet in 90 per cent of the examined cases, the sheriff made no recommendations. And even if a sheriff does call for changes, the SPS is not legally obliged to carry them out.

Several factors serve to neuter these inquiries. Much of the evidence is agreed in advance, so few witnesses are called. Unlike in England and Wales, where most cases of death in custody are heard by a jury, Scottish inquiries are presided over by a single sheriff. The time between the internal review, held within weeks of a death, and the inquiry allows the SPS to persuade sheriffs that systemic problems have been addressed. In addition, while the Crown, the SPS, the NHS and the Scottish Prison Officers’ Association have their own lawyers, the prisoner’s relatives are often unrepresented. In England and Wales, a campaign by the charity Inquest led to a change in the law, and since January 2022 bereaved families have been entitled to non-means-tested legal aid for all Article 2 inquests (deaths where the state had a duty to protect the deceased). This legislation doesn’t cover Scotland, though the Allans were granted legal aid after a public outcry.

The director of Inquest, Deborah Coles, has advised the Allans and the family of Sheku Bayoh, who died after being restrained by police officers in Kirkcaldy (Gordon Brown’s old parliamentary seat) in 2015. ‘Scotland is a country that talks about its commitment to human rights,’ she told me.

It does good messaging around immigration, and the 2012 Elish Angiolini report on female offenders led me to believe it was progressive. But I have come to see how the processes work here, and the reality of how families are treated. It’s been a shock to find out how bad the situation is.

Before Christine died in December 2021, the Allans promised to keep fighting for her son. William’s older half-brother, John Reilly, was also determined to see justice. In May 2023, the Crown took the unusual decision to hold a joint inquiry into Katie and William’s deaths. The suicides in Polmont hadn’t stopped. In September 2021, Jack McKenzie killed himself while on remand there. He was twenty. Then, in August 2023, with the preliminary hearings for the joint FAI finally underway, Duncan Anderson killed himself just three days after entering Polmont.

On​ 8 January 2024, a bank of photographers greeted the Allans as they climbed the stone steps of Falkirk Sheriff Court for the start of the inquiry. In William’s case, the timeline and mistakes made were clear. William had been sent to Polmont with two documents: his prison escort record, which said that, as a suicide risk, he had been subject to constant monitoring during the journey, and a note from the court social worker identifying him as a vulnerable person. Polmont should also have received an updated care plan from his social worker, Mark MacDonald, and a supervised bail report, but these were not passed on. The prosecution service did fax over a letter identifying him as a suicide risk. The prison officer, Christopher McAinsh, and mental health nurse, Brian Leitch, who carried out his reception risk assessment recorded some (but not all) of the information in these documents, and noted that William was ‘very nervous about his time in jail’. They put him on TTM, with checks every thirty minutes.

Leitch was also at the conference the next morning when William was taken off TTM, along with a different prison officer, Natalie Cameron, and the duty first line manager, John Dowell. Neither Cameron nor Dowell had looked at any of the documents before the meeting. They all agreed that William was calm and maintaining eye contact. No one suggested trying to obtain more information about his history of self-harm. Though Leitch knew that MacDonald’s phone number was on one of the documents, he didn’t consider contacting him. No one suggested that William should be kept on TTM until the mandatory review for a child on a compulsory supervision order was held the following Monday.

Any member of staff could have overturned this decision and put William back on TTM. Yet, despite further phone calls to the jail from MacDonald and an Includem worker called Stephen Cain – phone calls in which they talked about William’s recent threats to harm himself – and despite William telling an addiction worker that if he felt suicidal, he ‘wouldn’t tell anyone’, no one took action. A mental health referral from Andrew Doyle, a Polmont-based social worker, might have triggered a reassessment had it been handed to a mental health nurse. Instead, it was printed out and dumped in an in-tray. It was still there when William died.

Part way through the inquiry, a prison officer called Robert Baird took the stand. Baird, who gave up his job three months after William’s death, had contacted me after reading my article. He told me how guilty he felt. He should have attended the morning conference, but had been sidetracked. He shook and twisted his hands as he told the FAI that when he found out William had been removed from observation, he replied: ‘Please tell me that’s a fucking joke.’ His failure to reinstate the TTM order was, he said, ‘the worst decision of my career’.

In Katie’s case, prison staff had failed to connect a series of events – the loss of her hair, threats made against her, a row with her boyfriend – or to notice the deterioration in her mood. One officer, Jennifer Wilson, sobbed as she told how she had breached protocol to bring Katie bandanas to cover the effects of alopecia (Katie had winked at her every time she wore them). But the efforts to support her were ad hoc. Joanne Brogan, a mental health nurse and fellow alopecia sufferer, was asked to chat to Katie about her hair loss. But when Brogan wrote up the encounter, adding ‘follow up by mental health team’, this led the GP treating Katie to believe she was being formally supported by the Polmont mental health team and that her mental health was being assessed. This wasn’t the case.

There was shoddy form-filling and a lack of curiosity on the part of transient, under-trained staff. Information-sharing was flawed, both internally and externally. SPS staff couldn’t access the prison NHS system and health staff couldn’t access the prison IT system. No one had easy access to prisoners’ GP records. TTM seemed to be a tick-box exercise, with officers over-reliant on visual ‘cues and clues’ – such as eye contact – and on the prisoner’s own assessment of their mental health. All the prison staff who gave evidence to the inquiry were aware of the risk factors: first time in custody, history of self-harm, recent court appearances (including abandoned appeals), knowledge of a suicide attempt by someone else. But most young offenders fall into at least one of these categories. Prison officers wrongly believed that ‘concern’ forms were only to be used for logging worries voiced by family members and partner agencies. They rarely filled out the forms themselves: the logic was that if they had a concern they would act on it. But this meant there was no paper trail charting the decline in an individual’s mental health.

The sheriff overseeing the inquiry, Simon Collins, became exasperated with the focus on TTM. Almost all the suicides in Scottish prisons involve hanging, and he wanted to hear more about that. A range of experts gave evidence, including Gordon McKean, then head of technical and professional services for the SPS, who had carried out a ligature anchor point review in 2018. Bunk beds and doorstops had been identified as risks before Katie and William’s deaths and McKean highlighted their danger in his review. It would have taken very little money or effort to remove bunk beds from single occupancy cells, and doorstops could easily have been replaced with sloping, anti-suicide alternatives. McKean was trying to discuss his findings with the SPS when he was told he should instead produce a report on the cost of turning all cells into Safer Cells. McKean thought this was unrealistic and, given the misgivings prisoners have about Safer Cells – which usually appear bare and depressing – even undesirable. But his opinion wasn’t sought.

McKean put the cost of upgrading all the cells in Polmont at £17 million, and all the cells in the Scottish estate at £155 million. The SPS decided against this. Among the reasons given by its chief executive, Colin McConnell, to Humza Yousaf were that ligature-free cells would create a ‘restrictive, sterile environment’ and that prisoners might find other ways to kill themselves. He didn’t tell Yousaf that McKean had proposed more minimal changes, or that the reduction or elimination of ligature anchor points was SPS policy in new-build prisons. The bunk beds and doorstops were still in Polmont when the inquiry began.

In January 2024​ , as the inquiry was drawing to a close, it emerged that Sheriff Collins was planning to defer his determination until after the FAI into the death of Jack McKenzie, over which he would also preside. This meant that the Allans’ wait for a resolution would be prolonged, but also that claims by the prison service to have addressed the problems raised in the first inquiry would be tested. The inquiry into Jack’s death began last July, two days before the general election. This time, the court was quieter. Anwar wasn’t involved and the Allans had decided to stay away. Two of Jack’s relatives – his brother, Stephen, and his aunt, Caroline – turned up every day. Jack had been charged with rape and sexual assault, which he denied. I have been covering the courts long enough to know that, even when it comes to young offenders, those accused of sex crimes are the least likely to attract public sympathy. But Jack had seen more than his share of troubles. He had lost both parents to drug-related deaths by the age of eight, and his grandmother to cancer when he was twelve. He had witnessed domestic violence, been diagnosed with asthma and ADHD, and had suffered a fractured skull when he was deliberately knocked down by a car.

The inquiry was told that drugs are rife in Polmont, with spice, a synthetic cannabinoid, particularly problematic because it causes agitation and aggression. Jack had used drugs, including spice, and had been placed on a programme to manage substance abuse fourteen times in his seven months at Polmont, but had never been placed on TTM. The combination of the Covid pandemic and the drug programme meant that Jack was allowed out of his cell for as little as twenty minutes a day.

On the afternoon of 1 September 2021, Jack, upset over missing a court appearance that he thought might lead to his release, became disruptive and refused to go back to his cell. Prison officers suspected he had taken spice. They put him on fifteen-minute and then hourly observations, and invoked Rule 95, a disciplinary provision under which a prisoner is kept in isolation for up to three days. The next morning, when he wasn’t allowed to see his solicitor, Jack became angry again, smashing the hatch on his cell door. In the afternoon, he was examined and the observations stopped. The isolation punishment continued.

At 6.30 a.m. the next morning, 3 September, a prison officer called David Nelson, who was carrying out a hatch check at the end of the night shift, saw Jack’s cell had been trashed. He couldn’t see Jack. Night-shift officers conducting hatch checks were meant to gain visual and verbal confirmation of a prisoner’s wellbeing. If this was impossible, they were supposed to have the cell opened. Instead, Nelson spoke to a colleague, who told him that Jack was on Rule 95. Nelson wrongly assumed this meant he had been moved to the segregation unit. Around an hour later, an officer carrying out his morning rounds found Jack’s body. He had hanged himself from the door to the bathroom in his cell.

At the time of Jack’s death, Gerry Michie had just been appointed acting governor of Polmont. In 2022, he was appointed governor, a role he still holds. Michie told the inquiry that Nelson had not been reprimanded or retrained. Instead, the end-of-night checks had been scrapped – they weren’t standard procedure. Asked whether he thought the right message to send out was ‘you can not follow a rule and there will be no repercussions,’ Michie said he believed people should be treated with compassion and that not every error should result in a disciplinary process. The FAI heard that the bathroom door had been recognised as a suicide risk for at least a decade and had been used by several prisoners before Jack. It had been estimated that fitting anti-suicide alternatives in Polmont would cost £1200 per cell. Eleven Scottish prisoners have since hanged themselves in the same way.

The​ inquiries raised broader questions about Scotland’s approach to justice. Why are so many children and young people falling through the gaps? And why does the Scottish government keep talking up the benefits of a less punitive justice system while – along with England and Wales – jailing more people than any other country in Western Europe? Last June, Holyrood, like Westminster, was forced to sanction the emergency release of prisoners because its jails were overflowing. Yet by mid-September, the prison population stood at 8241, higher than before the emergency releases and 234 above its target capacity. The government has since brought in legislation allowing most prisoners jailed for less than four years to be freed after serving 40 per cent rather than 50 per cent of their sentence.

The number of young people in jails has declined across the UK over the last decade. In England and Wales, the number held in Young Offender Institutions and Secure Training Centres fell from 939 in 2015 to 434 in 2022. In Scotland, it dropped from 1012 in 2009 to 160 in 2022 (rising to 168 in 2023). New sentencing guidelines in Scotland state that under-25s should only be jailed as a last resort. But the government’s main focus has been on under-eighteens. Scotland’s care and youth justice systems are enmeshed; it is impossible to write about one without the other. In 2017, Nicola Sturgeon, who liked to style herself ‘chief mammy’, commissioned an Independent Care Review which found that, although the principles behind the Children’s Hearings System were sound, some of the structures were outdated and the relationship with social workers poor. As a result, decision-making was slow, children were moved from place to place and often languished in the system for years. This led to the announcement in February 2020 of what’s called the Promise – a commitment by the Scottish government to political and legislative change that will ensure children in its care grow up ‘loved, safe and respected’. As part of this, Sheriff David Mackie was appointed to lead a review of children’s hearings and recommended that panel members should be drawn from a wider demographic pool and that the role of chair should be enhanced and salaried, which the Scottish government has rejected.

In 2019, Holyrood raised the age of criminal responsibility from eight to twelve, the highest in the UK (it’s ten in England and Wales), though considerably lower than in many other countries, and lower than the age – fourteen – recommended by the United Nations Committee on the Rights of the Child. It also started paying secure units to keep some beds free for emergencies, so no under-eighteens on compulsory supervision orders should have ended up in Polmont. But those between sixteen and eighteen without compulsory supervision orders (the age limit for new referrals was sixteen) weren’t eligible for secure care units, so sheriffs continued to jail them. The Children (Justice and Care) Bill, passed in April 2024, made it illegal to send under-eighteens to Young Offender Institutions. Although £500,000 was given to the secure units to help them prepare for the transfer of young people from Polmont, by July no transfer had taken place. The number of under-eighteens in Polmont actually went up from two in November 2023 to nine in July 2024.

The inquiry into Jack’s death concluded on 12 July. Four days later, the government incorporated the UN Convention on the Rights of the Child into Scots Law. Nicola Killean, the children and young people’s commissioner for Scotland, posted on X: ‘Today is historic! The UNCRC is now part of Scots law, making children’s rights legally enforceable in Scotland.’ Minutes after I read this, Linda Allan phoned to tell me another teenager had hanged himself in Polmont. Jonathan Beadle, who was seventeen, had been moved from a secure unit after a sheriff realised he wasn’t subject to a compulsory supervision order. He was awaiting sentence after pleading guilty to acting in a disorderly manner and being in possession of weapons with intent to ‘assault and murder’ a teenage girl. As always, there was another side to him. At Polmont he had joined the youth theatre and taken part in its most recent production; Glass Performance, the organisation that runs the group, said its members were ‘absolutely devastated’ by his ‘utterly tragic death’. Six weeks later the new regulations were finally enforced and the remaining children moved from Polmont to the secure units.

For a short time,​ I had the rare sense of having done right by someone. No more under-eighteens would be sent to Polmont. But as the weeks dragged on, I began to worry about the standard of care in the secure units. Those I spoke to in the youth justice system seemed convinced they were a safer and more therapeutic option. But there have long been complaints about the overuse of restraint and a lack of transparency. In 2006, St Philip’s in Airdrie was shut down after a report highlighted child protection issues and the man who ran the centre was named as a suspect in an abuse inquiry. In 2023, Scotland’s last council-run secure unit, in Edinburgh, closed following ‘serious failures which compromised residents’ wellbeing and safety’.

Less than a month after the last under-eighteens were moved from Polmont, the Care Inspectorate ordered Scotland’s largest secure unit – St Mary’s Kenmure on the northern edge of Glasgow – to close to new admissions after finding that the use of high levels of restraint and dangerously low levels of staffing left child protection ‘consistently compromised’. Concerns about the quality of care at St Mary’s had first been raised in April 2023 when a Care Inspectorate report graded it two – ‘weak’ – out of a possible six. Six months later, it moved up to three – ‘adequate’. Now, despite the extra funding and all the focus on secure care, it had dropped to one – ‘unsatisfactory’.

The moratorium on admissions to St Mary’s meant that capacity was reduced just as demand was increasing. Over Christmas, there were days when there was only one place in a secure unit available in Scotland. The Labour MSP Pauline McNeill asked Natalie Don-Innes, the minister for children, what would happen to a young offender if there wasn’t a place for them in a secure unit. Don-Innes said there had been a drop in the number of secure unit placements required (from an average of 74 in 2021 to 59 in 2022) and that the Scottish government’s commitment to paying for up to sixteen beds for young offenders was providing a level of financial security to the companies running the units and reducing their reliance on cross-border placements. She said consideration was being given to expanding the capacity of at least one of the sites. But she didn’t answer the question.

On 16 January, Sheriff Collins’s determination on the deaths of William Lindsay and Katie Allan was finally issued. I hadn’t anticipated its fullness or its frankness: 419 pages, 25 recommendations, too many criticisms to count. He ruled both suicides preventable. He wrote that William’s death resulted from ‘a catalogue of individual and collective failures by Scottish Prison Service and healthcare staff’ and that ‘almost all those who interacted with him were at fault to some extent.’ In both cases, Collins identified multiple instances where information had not been properly documented or shared, and, in Katie’s case, noted a systemic failure to use concern forms. He described her suicide as ‘spontaneous and unpredictable’, but pointed out that there was ‘no single, readily accessible source of all the information relevant to [her] risk of suicide available to SPS staff in Polmont. There was therefore no system by which a proper, ongoing/dynamic assessment of her risk of suicide could be carried out.’ He ruled that her death could have been avoided had she been placed in a cell without a doorstop. He noted that the internal reviews carried out after both deaths hadn’t even mentioned the possibility of removing fixtures in cells that could be used to anchor ligatures.

Get the bunk beds out of single occupancy cells, Collins instructed. Replace the doorstops. Design an anchor point audit, then carry it out. Analyse the audit, make a plan, act on the plan, publish progress reports. Basic stuff, you might think, but in the six years since Katie and William died, the prison service had failed to do any of this. Other recommendations were aimed at improving information-sharing. Collins told the Scottish government to come up with a system for the reliable transfer of documents relating to young offenders from court to prison. He said TTM should be revised to emphasise the increased risk to prisoners during the first 72 hours in custody and during weekends, and should contain specific guidance about obtaining background information on a prisoner’s suicide risk.

I asked Linda Allan what she thought. ‘It is everything we could have hoped for,’ she replied. ‘It’s just a pity it can be ignored.’ For the last year, Inquest has been campaigning for a national oversight mechanism to collate, analyse and follow up on recommendations arising from inquests, fatal accident inquiries and public inquiries, and the Allans have called for such recommendations to be legally enforceable. They have also called for the overhaul of FAIs and for bereaved Scottish families to be guaranteed state-funded legal representation in death-in-custody inquiries. Finally, they asked again how state-run prisons can be forced to take their responsibilities seriously when they are immune from prosecution under the Health and Safety Act. Sheriff Collins had not been tasked with addressing Crown immunity, but wrote in his report that it ‘might appear anomalous, particularly given that NHS Trusts no longer have such protection, and indeed have been successfully prosecuted and fined in relation to in-patient suicides arising from a failure to adequately manage ligature anchor points in secure mental health wards’. Had the issue fallen within the purview of the FAI, he went on, ‘it might have been argued that [the] SPS had to some extent an institutional culture resulting from such immunity in which there were insufficiently robust systems for attributing responsibility for individual failures and attaching sanctions thereto.’ In other words, the Scottish Prison Service knows it’s untouchable.

The SPS should brace itself for further condemnation when Collins’s determination on Jack McKenzie’s death is published later this year. By drawing attention to the inadequacy of previous FAIs, Collins has raised the bar for future inquiries. It will be much harder now for a sheriff to dismiss a prison suicide as just something that happens to people like that. The week after his determination was released, the Allans and John Reilly went to Holyrood to meet the first minister, John Swinney, and the justice minister, Angela Constance, both of whom apologised to them. In the chamber, Constance announced the following changes: the SPS will review its policy on ligatures and work on suicide prevention technology; Talk to Me will be revised and all information from relevant agencies will be shared with the SPS at the time of admission to prison; internal reviews will now be independently chaired and consider the safety of the prisoner’s physical environment; legal aid will be available to all bereaved families in death-in-custody inquiries; there will be a review of FAIs, which will report by the end of the year. She also announced a new, independent national oversight mechanism to monitor the implementation of recommendations from FAIs and public inquiries. She added that the Scottish government would press Westminster for action on Crown immunity.

All of this may come to something, or it may not. There is no set timetable for delivery and the Scottish government has so far been unable to clarify whether the oversight mechanism or the extension of legal representation will require legislation. Katie Allan’s suicide forced Scotland to examine its conscience because she was grievable. She was middle class, white and pretty, a university student who had made one huge mistake – it was easy for people to feel sympathy for her. But her death made a difference because her family believed that children like William Lindsay, who had a very different upbringing and experience of the justice system, were grievable too.

I asked Linda what Katie would have thought about her campaigning. ‘I struggle with that,’ she replied, ‘because if there was one thing she did not want it was to be defined by her offence.’ She took me to visit Katie’s favourite beach, near Arisaig, a white bay hidden by gorse and marram grass. In the distance I could see the Cuillins’ icy peaks. Had Katie not died in Polmont, she would have been out of prison long ago. It’s hard not to think about where they all might be now. Katie collecting shells on her beach, William home in Possilpark with his dog, Jack back with his brother, Steven, and his aunt, Caroline. Somewhere else, anywhere else, living their lives.