Transgender prisoner suicide 'could have been avoided'

Sarah Jane Riley died in Perth Prison in January 2019

The death of a transgender prisoner at Perth Prison would have been avoided if a suicide prevention strategy had been in place, an inquiry has ruled.

Sarah Jane Riley died on 12 January 2019 in solitary confinement, a day after being refused release from prison on licence.

A Fatal Accident Inquiry (FAI) was told that the prison was "not equipped" to deal with the "sudden arrival" of a transgender inmate who was subject to an Order for Lifelong Restriction (OLR), with "multiple personality disorder diagnoses."

Sheriff Pino Di Emidio made eight recommendations including training for staff on the impact of OLRs on prisoners.

Riley, then known as Aiden Riley, was jailed for 32 months in December 2008 for stabbing a man in Aberfeldy.

An OLR was also imposed, meaning Riley would only be released on licence when the parole board was satisfied it was safe to do so.

In 2015, while in Castle Huntly open prison, Riley began living as a female and the Scottish Prison Service (SPS) recognised Riley's protected status as a trans woman.

After an unsuccessful transfer to Cornton Vale women's prison, Riley was transferred to Perth Prison, intending to live as a male, but then changed their name to Sarah in 2016.

After being released to charity accommodation in 2018, Riley breached their licence and was recalled to Perth Prison.

An initial assessment at Perth reception noted "good communication, no thoughts of suicide or self-harm at this time and presents well" and assessed Riley as "no apparent risk."

Sheriff Di Emidio noted: "The nomination of Perth as the committal establishment upon the recall of Sarah meant that those who had to deal with her there were faced, without any notice, with difficult and sensitive decisions which involved the need to balance competing rights and interests.

"Perth was not equipped to deal with the sudden arrival of a prisoner who presented three serious sets of issues.

"She was an OLR prisoner of long-standing just recalled, she had multiple personality disorder diagnoses, and she was a transgender woman."

Segregated unit

The inquiry heard that Riley had been in a single cell in a segregated unit from the time of admission until their death.

Riley was remanded in Perth Prison on 6 November 2018 and placed in solitary confinement "without legal authorisation for a period of about 18 days".

A transgender case conference was convened on November 12, 2018 which heard Riley should be moved to Polmont Prison, however Riley said they "felt safe" in Perth Prison, according to the judgment.

Riley was then moved to another segregated cell in Perth on 24 November when the prison governor made an order under Rule 95 "to authorise Sarah's removal from association for her protection as a trans woman."

It heard that the Scottish Prison Service's (SPS) equality and diversity manager was concerned that Riley had been returned to a Perth as they had been living in the community as a woman for some time.

In his view, the SPS transgender policy required Riley should have been placed in the female estate.

The prison social worker met Riley many times and thought that staying at Perth was the best option, given there was family nearby and links to the community.

The sheriff noted: "No one higher in the prison hierarchy seems to have been aware of her view.

"The only course pursued was to seek a transfer."

'Previous adverse experiences'

When HMP Edinburgh refused to accept Riley, saying it already had too many transgender prisoners, a proposed transfer to Polmont was discussed, but Riley refused to go due to "previous adverse experiences."

The inquiry said Riley made a request for a mental health assessment, but "no action appears to have been taken in response to this request."

It said Riley had expressed some concern about moving to a female prison due to problems encountered at Cornton Vale.

On 8 January 2019, Riley attended an OLR tribunal hearing within Perth Prison.

The inquiry noted that "there was no practical route to being released on licence again from Perth other than by way of a progression to the open estate usually at Castle Huntly."

Riley was refused parole on 11 January and was found dead the following day.

The inquiry was told that that staff who were worried about prisoners could complete a "concern form", which initiated the Talk to Me (TTM) suicide prevention strategy.

However, at the time, there was no requirement in the TTM strategy to include a requirement for risk assessments being undertaken following receipt of "adverse parole decisions."

The process was revised to include this in December 2019, 11 months after Riley's death.

'Inappropriate use of segregation'

The sheriff said that a defect in the system of working contributed to Riley's death.

He said: "There was no system in place to allow for the formulations available in respect of OLR prisoners regarding their risk to others to be reformulated to identify a prisoner's risk to themselves, although this could easily be done."

The sheriff added that with the benefit of the relevant knowledge the segregation unit staff would have identified that the parole board decision was likely to have a "significant detrimental impact" and Riley should have been placed on the TTM strategy.

The sheriff said: "Had that been done her death would have been avoided."

He added: "This is an example of the inappropriate use of segregation for a prolonged period in circumstances where the prisoner had not acted in a manner that merited removal from association."

The sheriff recommended that Scottish Ministers and SPS should consider establishing a system for prisoners on an OLR to have a "psychological formulation" focused on the prisoner's risk to themselves.

He said the SPS and Scottish Ministers should consider the requirement for an urgent case review within seven days of the arrival of a recalled prisoner, who is within the scope of the current transgender policy "to decide if the prisoner should be transferred to another prison."

The sheriff added that where an OLR or transgender prisoner has been segregated for more than 30 days for their safety, an urgent review should be carried out.

'Thoughts and condolences'

A Scottish Prison Service spokesperson said: "Our thoughts and condolences continue to be with the family of Sarah Riley.

"We are grateful to Sheriff Pino Di Emidio for his recommendations, which we will fully consider, as we continue to work to support the needs and wellbeing of all people in our care, during one of the most challenging and vulnerable periods of their lives."