Katie Allan, 21, and William Lindsay, 16 took their own lives within months of each other while held at Polmont YOI in 2018.
Ms Allan, a student at Glasgow University, was found dead in her cell on June 4 while serving a 16-month sentence for drink-driving and causing serious injury by dangerous driving.
Mr Brown, who had been in care repeatedly, was found dead in his cell on October 7, three days after being admitted as there was no space in a children’s secure unit, having walked into a police station with a knife.
A fatal accident inquiry (FAI) into their deaths was held at Falkirk Sheriff Court last year, led by Sheriff SG Collins KC.
William Lindsay and Katie Allan (Image: Family) In his determination, which was published on Friday, Sheriff Collins described a “catalogue of individual and collective failures by prison and healthcare staff” at the facility.
He found there were reasonable precautions by which both deaths might realistically have been avoided, and that systemic failures contributed to them.
The findings, which stretched to 419 pages, are the longest issued in Scotland in more than 50 years of fatal accident inquiries.
Justice Secretary Angela Constance is to make a statement to the Scottish Parliament on the results of the FAI next week.
Responding to the verdict, Katie Allan’s mother Linda said her daughter was “brutalised” in Polmont
She said: “She lost all hope and saw only one solution; her death. She did not ‘thrive’ as claimed by a witness at her FAI – she was bullied, she was petrified, she was lost.
“She lost her hair and was taunted, her mental health suffered, and one nurse couldn’t even be bothered recording accurate records on their antiquated systems.”
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In his determination, which was published on Friday, Sheriff Collins described a “catalogue of individual and collective failures by prison and healthcare staff” at the facility.
He found there were reasonable precautions by which both deaths might realistically have been avoided, and that systemic failures contributed to them.
However, the FAI’s recommendations to avoid similar deaths are advisory, and will be left to the SPS’ discretion to implement.
Mrs Allan said the findings should be mandatory, otherwise the FAI system was “broken”.
She said: “Scotland enjoys spouting forth human rights platitudes. You would be forgiven for even believing them. There are no human rights upheld in our story.
“Katie was not afforded her right to life and we have not been afforded a prompt or transparent investigation into Katie’s death.
“The prison service literally gets away with creating the circumstances by which people die prematurely. No sanctions exist. They cannot be criminally prosecuted.
“Unless this changes, another Katie or another William will lose their lives, 3 have already done so in Polmont since 2018.”
One of the main issues identified by Sheriff Collins was the effectiveness of the Talk To Me (TTM) suicide prevention strategy at Polmont, through which at-risk prisoners are subjected to increased observation and checks.
Ms Allan had not been considered a “risk” when she was admitted to Polmont and so was not placed on TTM.
However, the Sheriff said that during her incarceration there was a “systemic failure” by prison staff to complete “concern forms” that could have triggered the TTM process, pointing to a number of incidents recorded by prison staff that should have been red flags.
These included, he said, the fact Ms Allan was being bullied by other prisoners, distress caused by hair loss resulting from alopecia, her distress at being body (strip) searched by prison staff, and the failure of her appeal against her conviction.
Her weight also dropped from 65kg to 58kg during her 12 weeks at the facility, which Sheriff Collins said should have been a “cause for concern” by staff.
Mr Brown, who had a long history of suicidal ideation, was placed on TTM on admission to Polmont only to be removed from it the next morning, despite presenting as a “very high risk” individual.
John Reilly (Image: NQ/Colin Mearns) His brother John Reilly said: “My mother Christine never stopped crying after William’s loss, but she also never gave up fighting but in the end, she died of a broken heart in December 2021.
“Why could this ever be allowed to happen to a child? He was my baby brother; he was just a terrified little boy.
“It seemed to me that Polmont essentially could not afford to keep William alive, which is a horrible and distressing thought.”
He added: “My mother Christine never got to see today. The only thing I know is that William’s and Katie’s legacy must be real change, not empty promises.
“Whilst some would call the system corrupt, I just call it the Scottish Prison Service – who act as they though are a God, with a total freedom to kill.
“There are those who should be in prison for William’s death, yet they have never suffered any consequences and it is time the law was changed.”
Polmont Young Offenders Insitute (Image: NQ) Lawyer Aamer Anwar, who has represented both families, said that he intended to take the fight to the UK Government and campaign for the SPS’ immunity from prosecution to be removed.
He said: “The Scottish Prison Service, former prison governors, senior management at Polmont the Forth Valley Heath Board, as well as Scottish Government, first ministers and successive 3 justice ministers – you should hang your heads in shame. You are complicit in the deaths that continue to take place.
“You did more than fail the most vulnerable people in our society, you ignored their cries for help, we do not have a death sentence in this country but for Katie and William that is what you served on them.
“The families do not want your empty soulless words of sorrow and condolences, for over six years you denied the truth, lied and conducted a whitewash, you gaslighted the families, and the fact is some of you should be facing criminal prosecution, but whilst Crown Immunity remains, you will remain secure in your lack of accountability.
He added: “To be clear; The Crown Office told us before the FAI commenced there was more than sufficient evidence to prosecute the Scottish Prison Service for the deaths of Katie and William under health and safety laws but because they have crown immunity nothing could be done.
“It is time this archaic law, this license to kill was changed by the UK Government for all prisons throughout the UK.”
A spokesman for the SPS added: “Our thoughts remain with the families of Katie Allan and William Lindsay and we would like to take this opportunity to offer our sincere condolences and apologies for the failures identified in this report.
“We are committed to doing everything we can to support people and keep them safe during the most challenging and vulnerable periods of their lives.
“We are grateful to Sheriff Collins for his recommendations, which we will now carefully consider before responding further.”