A recent Fatal Accident Inquiry (FAI) has concluded that the tragic death of a vulnerable transgender inmate, Sarah Riley, within the walls of HMP Perth could have been entirely prevented. The 29-year-old, originally from Perthshire, ended her life in 2019, mere hours after receiving news that her bid for release from custody had been denied.
Riley, who identified as female, was the sole transgender woman among approximately 660 male prisoners at the correctional facility. Her complex background included a history of significant mental health challenges and prior suicide attempts. At the time of her death, she had spent over nine weeks in a segregation unit, a placement attributed to administrative delays in transferring her to an all-female institution. The FAI heard that her passing occurred shortly after she learned of the Parole Board’s decision to keep her incarcerated. Crucial Information Withheld
The Sheriff overseeing the inquiry delivered a stark judgment, stating, “The deceased was a prisoner with complex needs, but the staff could have been given the available information about her complexities. With the benefit of the relevant knowledge the SRU (Separation and Reintegration Unit) staff would have identified that the PBS (Parole Board for Scotland) decision was likely to have a significant detrimental impact on Sarah such that should be placed on the Talk to Me suicide prevention strategy. Had that been done her death would have been avoided.”
This ruling underscores a critical lapse in communication and care, suggesting that key information regarding Riley’s mental state and vulnerabilities was not adequately shared or acted upon by those responsible for her welfare. The implication is that a more informed approach could have triggered vital protective measures, potentially altering the tragic outcome. A History of Instability and Systemic Gaps
Riley had been returned to prison in November 2018, just four months after her initial parole release, following alleged breaches of her Order for Lifelong Restriction (OLR). These breaches reportedly stemmed from issues involving alcohol, drugs, and threatening behaviour while residing in supported accommodation in Perth. Her original OLR, issued by the High Court in Edinburgh in 2008 when she was 18 and known as Aiden, followed a conviction for a knifing incident in Aberfeldy.
During the inquiry, Sheriff Pino Di Emidio noted that Riley’s extended placement in the segregation unit was “without legal authorisation” for an 18-day period. This prolonged isolation, combined with delays in finding a suitable female-only facility (despite Riley’s preference to remain in Perth), exacerbated an already precarious situation. She was tragically discovered deceased on January 12, 2019.
Poignant evidence presented to the inquiry included a prison document in which Riley had written: “I have given up. Any representations I make are just pointless endeavours. No matter what I write, if I don’t get out at my tribunal I will never get out. Should that happen I will disengage entirely.” These words paint a grim picture of her deteriorating hope and growing despair within the system. Missed Opportunities for Intervention
Despite being an OLR prisoner, subject to extensive risk management, the inquiry found that these processes predominantly focused on the risk she posed to others, rather than her own self-harm risk. The Sheriff highlighted the absence of a robust system to assess and mitigate the risk to prisoners like Riley, particularly in response to emotionally charged events such as a Parole Board rejection. Such a system, he suggested, would have provided staff with a clearer understanding of the profound impact of the decision not to release her.
In his comprehensive 109-page written judgment, Sheriff Di Emidio concluded that the case exemplified 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.” He further criticised the slow progress in transferring Riley once the prison authorities had decided she needed to move in line with policy, noting that her accommodation within the Separation and Reintegration Unit was “not well managed.” Recommendations for Reform in Scotland’s Penal System
The inquiry’s findings detailed a series of procedural failures that collectively contributed to the tragic outcome. As a direct result, Sheriff Di Emidio has urged Scottish Ministers and the Scottish Prison Service to consider implementing eight specific measures. These recommendations aim to improve the management and care of prisoners placed in solitary confinement, with a strong emphasis on assessing their mental health and ensuring that senior prison staff are fully informed of their status and vulnerabilities.
A spokesperson for the Scottish Prison Service acknowledged the gravity of the situation, stating: “We recognise the profound impact the death of someone in our care has on their loved ones, and 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.”
This ruling serves as a powerful reminder of the intricate challenges faced within Scotland’s correctional facilities, particularly concerning the mental health and appropriate care of its most vulnerable inmates. The hope is that these recommendations will lead to tangible reforms, ensuring that no other individual in a similar situation within Perth Prison, or indeed any Scottish facility, falls through the cracks of a system designed to hold them.
Riley, who identified as female, was the sole transgender woman among approximately 660 male prisoners at the correctional facility. Her complex background included a history of significant mental health challenges and prior suicide attempts. At the time of her death, she had spent over nine weeks in a segregation unit, a placement attributed to administrative delays in transferring her to an all-female institution. The FAI heard that her passing occurred shortly after she learned of the Parole Board’s decision to keep her incarcerated. Crucial Information Withheld
The Sheriff overseeing the inquiry delivered a stark judgment, stating, “The deceased was a prisoner with complex needs, but the staff could have been given the available information about her complexities. With the benefit of the relevant knowledge the SRU (Separation and Reintegration Unit) staff would have identified that the PBS (Parole Board for Scotland) decision was likely to have a significant detrimental impact on Sarah such that should be placed on the Talk to Me suicide prevention strategy. Had that been done her death would have been avoided.”
This ruling underscores a critical lapse in communication and care, suggesting that key information regarding Riley’s mental state and vulnerabilities was not adequately shared or acted upon by those responsible for her welfare. The implication is that a more informed approach could have triggered vital protective measures, potentially altering the tragic outcome. A History of Instability and Systemic Gaps
Riley had been returned to prison in November 2018, just four months after her initial parole release, following alleged breaches of her Order for Lifelong Restriction (OLR). These breaches reportedly stemmed from issues involving alcohol, drugs, and threatening behaviour while residing in supported accommodation in Perth. Her original OLR, issued by the High Court in Edinburgh in 2008 when she was 18 and known as Aiden, followed a conviction for a knifing incident in Aberfeldy.
During the inquiry, Sheriff Pino Di Emidio noted that Riley’s extended placement in the segregation unit was “without legal authorisation” for an 18-day period. This prolonged isolation, combined with delays in finding a suitable female-only facility (despite Riley’s preference to remain in Perth), exacerbated an already precarious situation. She was tragically discovered deceased on January 12, 2019.
Poignant evidence presented to the inquiry included a prison document in which Riley had written: “I have given up. Any representations I make are just pointless endeavours. No matter what I write, if I don’t get out at my tribunal I will never get out. Should that happen I will disengage entirely.” These words paint a grim picture of her deteriorating hope and growing despair within the system. Missed Opportunities for Intervention
Despite being an OLR prisoner, subject to extensive risk management, the inquiry found that these processes predominantly focused on the risk she posed to others, rather than her own self-harm risk. The Sheriff highlighted the absence of a robust system to assess and mitigate the risk to prisoners like Riley, particularly in response to emotionally charged events such as a Parole Board rejection. Such a system, he suggested, would have provided staff with a clearer understanding of the profound impact of the decision not to release her.
In his comprehensive 109-page written judgment, Sheriff Di Emidio concluded that the case exemplified 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.” He further criticised the slow progress in transferring Riley once the prison authorities had decided she needed to move in line with policy, noting that her accommodation within the Separation and Reintegration Unit was “not well managed.” Recommendations for Reform in Scotland’s Penal System
The inquiry’s findings detailed a series of procedural failures that collectively contributed to the tragic outcome. As a direct result, Sheriff Di Emidio has urged Scottish Ministers and the Scottish Prison Service to consider implementing eight specific measures. These recommendations aim to improve the management and care of prisoners placed in solitary confinement, with a strong emphasis on assessing their mental health and ensuring that senior prison staff are fully informed of their status and vulnerabilities.
A spokesperson for the Scottish Prison Service acknowledged the gravity of the situation, stating: “We recognise the profound impact the death of someone in our care has on their loved ones, and 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.”
This ruling serves as a powerful reminder of the intricate challenges faced within Scotland’s correctional facilities, particularly concerning the mental health and appropriate care of its most vulnerable inmates. The hope is that these recommendations will lead to tangible reforms, ensuring that no other individual in a similar situation within Perth Prison, or indeed any Scottish facility, falls through the cracks of a system designed to hold them.