Death of Barlinnie prisoner who took own life 'could have been avoided'

The death of a Barlinnie prisoner who took his own life was due to systematic failings and could have been avoided.

Michael Charlton died in his cell at the prison on October 28, 2019.

The 34-year-old was among three other prisoners who were found dead in Scottish jails in the space of five days.

Paul Hamilton, 43, died at Barlinnie on October 24, and Neil Hand, 30, then died at Low Moss on October 27. Another man died at Barlinnie, also on October 27.

A Fatal Accident Inquiry into Mr Charlton’s death found that it could have been avoided and identified systematic failings in the management of at-risk prisoners in his determination.

Sheriff Jonathan Guy found that officers at the prison failed to observe Mr Charlton every 15 minutes despite the instructions from healthcare staff.

It was also found that they failed to initiate the Scottish Prison Service’s suicide prevention system, Talk to Me, when Mr Charlton said to an officer that he intended to take his own life.

He recommended that the Scottish Prison Service implement clearer accountability for observations, improved handovers, enhanced training, and stronger monitoring and review arrangements.

The sheriff also recommended reforms to substance risk and suicide-prevention systems and completion of ligature risk assessments to help prevent further deaths.

A Scottish Prison Service spokesperson added: “We would like to offer our sincere condolences and apologies to the family of Michael Charlton for his sad death and the failings identified in this report.

“We are grateful to Sheriff Guy for his recommendations, which we will fully consider as we continuously seek to improve how we support people in our care.”

Procurator discal Andy Shanks for the Crown Office and Procurator Fiscal Service, Scotland’s independent deaths investigation authority, said:  “The determination is critical of aspects of the Scottish Prison Service’s management of at-risk prisoners, the risk assessment of cells and the effectiveness of internal learning reviews.

“The sheriff makes clear recommendations aimed at strengthening the management of individuals at risk due to substance misuse, suicide prevention and improving accountability.

“The FAI followed a thorough and comprehensive investigation by the Procurator Fiscal, who ensured that the full facts and circumstances of Mr Charlton’s death were presented in evidence.  

“While an FAI does not attribute blame or establish liability, it plays a vital role in ensuring that lessons are identified and acted upon in the public interest.”