Inquiry into the circumstances of the death of Mr Thomas James Strain [2010] FAI 43

The Sheriff found in terms of section 6(1) of the Fatal Accidents and Sudden Death Inquiry (Scotland) Act 1976, that Mr Thomas James Strain died between 13:00 and about 16:30 hours on 23 November 2008 at HMP Bowhouse, Kilmarnock. The Sheriff determined that the cause of death was hanging.
Having heard evidence and submissions, the Sheriff noted that there were no reasonable precautions whereby the deceased's death might have been avoided, nor where there are any system defects which contributed to the deceased's death.

Mr. Strain was a 46 year old man serving a 22 month sentence of imprisonment. He was found hanged in his cell at HMP Bowhouse, Kilmarnock, a facility managed privately by SERCO.
The Sheriff noted that a psychiatric report produced at sentencing diet was not available to prison staff during Mr Strain's initial reception to Bowhouse. The report was also unavailable during subsequent risk assessment processes and case conferences during Mr Strain's imprisonment.

In the weeks prior to Mr Strain's death, the Sheriff noted that he had been informed that he would not be released early under the Home Detention Curfew scheme. He was additionally experiencing negative press coverage in the tabloid press, which had not been received well by fellow inmates, resulting in taunting and harassment. On the date of death, the Sheriff noted that Mr Strain had been due to have a visit from his mother, but that prior to this visit, his body had been found suspended by a belt within the toilet area of his cell. Prior to this discovery, Mr Strain's cellmate had been asleep, and there had been no indications of Mr Strain's endeavours to take his own life.

Having heard technical evidence about the design of the toilet door in the cell concerned, the Sheriff noted that even if it were altered, a number of suspension points would still exist, and while it would be harder to secure a knotted ligature, it would not prevent the pursuit of someone who was determined to take his own life.

The Sheriff further noted that it was clear the psychiatric report had not been brought to the attention of prison staff. Noting that the absence of the psychiatric report was not material to the outcome in the case, the Sheriff noted that in other cases it would be vital to properly assess the risk of self harm of suicide of other inmates, and therefore, immediate access to any existing psychiatric reports was required upon prison reception. The Sheriff opined that there was merit in introducing a standardized practice whereby court staff would contact prison staff in advance, to alert them that an incoming prisoner would be accompanied by a copy of their psychiatric report.

The Sheriff noted that although the Inquiry had highlighted communication and procedural failings, it was not possible to say that any of these failings played a role in Mr Strain's death, there being no evidence of any redesign of the cell door which would have made it likely Mr Strain was diverting from the course he ultimately took. Equally, there was no evidence of any warning signs that Mr Strain was contemplating taking his own life, his decision being impulsive. There were no reasonable precautions by which this might have been avoided.