A 19-year-old inmate of Polmont Young Offenders Institution died in hospital less than a week after attempting suicide while in custody.
Liam Kerr was on remand at the YOI over allegations he had robbed a sandwich shop in his home town of Paisley.
A fatal accident inquiry at Falkirk Sheriff Court yesterday heard Kerr, who was is said to have “complex” mental health needs, had been in the prison for nearly eight weeks before the incident, in January 2017.
On the evening of January 13, 2017, he made the attempt on his own life only hours after being seen by an NHS psychiatrist who ruled out an immediate transfer to a psychiatric ward.
He died in hospital six days later.
Psychiatric nurse Brian Leech told the court he had been on duty at the weekend before the incident, when he was called to the segregation unit where Liam – diagnosed on a previous prison admission as suffering from drug-induced psychosis – was being held due to his “behaviour”.
Mr Leech (61) told the court he had received a call from the staff of the unit saying Liam was acting “very strangely”.
When he arrived he saw Liam was in the exercise yard.
Mr Leech said: “He was shouting – not making any real sense as far as I could see – and pacing about the yard.”
He added Liam’s cell was in a mess.
He said he talked to him, and Liam “settled himself down” and went back to his cell.
The next day he saw him again, and found him “shouting and screaming” and pacing round his cell.
Mr Leech said Liam was by now “difficult to reason with”, but he had been placed on medication to help him sleep, and he arranged for him to be seen by another nurse the next day.
He said: “I was thinking, if he gets a good night’s sleep on the Sunday night, maybe he’d be different on the Monday. But apparently he wasn’t.”
Mr Leech said he had not activated the Scottish Prison Service’s suicide prevention protocol, known at that time as Act To Care, as Liam was not presenting with any signs he was at risk of self-harm or suicide.
Mr Leech said: “He just seemed to be very excitable and very vocal.”
Then, on the following Friday, January 13, he was present when Liam was seen at the jail by NHS Forth Valley consultant psychiatrist Dr Rosa Serrano.
He said: “Liam was totally different from when I saw him at the weekend. He seemed a lot worse. He wasn’t making any sense, and you couldn’t bring him back to talk to him rationally.”
He said he understood the psychiatrist’s view was Liam’s condition was “deteriorating” and he was placed on anti-psychotic medication.
Mr Leech said: “The view of the doctor was hospitalisation wasn’t necessary at that point. The plan was to see if the anti-psychotic medication would work.”
He said Liam was being checked every hour by prison officers under the so-called “Rule 95” segregation protocol, but he conceded if Liam had been placed on Act To Care he might have been placed on “increased” observations.
Mr Kerr’s brother, Sean Kerr, said there had been a “lack of liaison” about Liam’s history of mental illness.
Mr Kerr (28) said: “Liam wasn’t himself. There were reports he was screaming for support. There should have been an action plan, and I’m struggling to understand why there was no referral to the suicide prevention team.”
The inquiry, before Sheriff Derek Livingston, which is scheduled to last at least two days, continues.