Fatal Accident Inquiry into the Death of Bryan Ross, Sheriff Neil Douglas, Paisley Sheriff Court, 23rd February 2011

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Bryan Ross died at the Kibble Educational and Care Centre, Goudie Street, Paisley, sometime around midnight on 20th/21 July 2009 and was pronounced dead at 0210 hours on 21 July 2009. In terms of section 6(1)(b), the cause of death was hanging. Formal determinations were made under section 6(1)(c), (d) and (e).

Bryan was a thirteen year old boy at the time of his death. He came from a troubled background and had behavioural problems. He resided at the Kibble secure residential facility from 27th March 2009 until his death. Around midnight on 20th/21st July 2009 Bryan hanged himself in his secure bedroom by means of a ligature formed from his dressing gown. Bryan should not have been left with his dressing gown in his bedroom overnight and its removal was overlooked. His body was discovered as a result of a routine check. Checks should have taken place every fifteen minutes from bedtime until midnight. The checking on that evening was of a lesser frequency. There were no signs during his time at Kibble that he would consider acting in the way he did. Accordingly, it was not established that Bryan intended to kill himself.

Determination:
Under section 6(1)(c) made the sheriff made two findings. First, staff members should have ensured that Bryan's dressing gown was removed and placed in a locked cupboard. However, other material in the room, such as bedding, could have been used as a ligature therefore it was impossible to find that the removal of the gown would have prevented death. Second, staff should have carried out fifteen minute observations until midnight. However, even if this had occurred it may not have affected the outcome.

Under section 6(1)(d) the sheriff found that the absence of a written policy on the frequency of observations was not a defect as the orally communicated policy was reasonably clear to staff members. Under section 6(1)(e) the sheriff found that there was no causal connection between the matters which might be raised under this section and the death.