Michael Charlton, 34, was found dead in his cell within HMP Barlinnie in the late afternoon of 28 October 2019. Mr Charlton was in legal custody and in the care of the state at the time of his death.
In his determination, Sheriff Jonathan Guy concluded that Mr Charlton’s death may have been avoidable and identified systemic failings in the management of at‑risk prisoners.
The sheriff made nine recommendations to strengthen the management of at‑risk prisoners, including clearer accountability for observations, improved handovers, enhanced training, and stronger monitoring and review arrangements, alongside reforms to substance risk and suicide‑prevention systems and completion of ligature risk assessments to help prevent future deaths.
The Procurator Fiscal, who acts in the public interest, led evidence on the facts and circumstances of Mr Charlton’s death at the FAI in which other interested parties were represented.
Following publication of the determination, Procurator Fiscal Andy Shanks for the Crown Office and Procurator Fiscal Service, Scotland’s independent deaths investigation authority, said:
“The determination is critical of aspects of the Scottish Prison Service’s management of at-risk prisoners, the risk assessment of cells and the effectiveness of internal learning reviews.
“The sheriff makes clear recommendations aimed at strengthening the management of individuals at risk due to substance misuse, suicide prevention and improving accountability.
“The FAI followed a thorough and comprehensive investigation by the Procurator Fiscal who ensured that the full facts and circumstances of Mr Charlton’s death were presented in evidence.
“While an FAI does not attribute blame or establish liability, it plays a vital role in ensuring that lessons are identified and acted upon in the public interest.”
Further information
For more information on Fatal Accident Inquiries, see the Crown’s guide.