Trans inmate died by suicide after unlawful segregation, sheriff rules

A transgender female prisoner took her own life after being unlawfully segregated amid a dispute over an unwanted transfer to a women’s prison, a sheriff has found after a fatal accident inquiry.

Sarah Jane Riley died shortly before her 29th birthday on January 12 2019, taking her own life while in solitary confinement in Perth Prison after learning of an unfavourable decision from the parole board.

In 2008, aged 18, Riley was sentenced to a Order for Lifelong Restriction (OLR), and was first remanded in Perth Prison in December 2007 when she was assessed as being suicidal. She died there 12 years later.

Riley lived as a gay man before starting the process of transition in February 2015, and began hormonal treatment in 2016 at the Sandyford Clinic in Glasgow after being diagnosed with gender dysmorphia, as well as three other complex personality disorders.

A fatal accident inquiry at Falkirk Sheriff Court heard Riley was unlawfully remanded in solitary confinement for 18 days in the Segregation and Reintegration Unit (SRU) after being recalled to Perth Prison, while a dispute around moving her to the female prison estate, which she objected to due to previous negative experiences, continued “with no end in sight” to her isolation.

Sheriff Pino Di Emidio made 12 recommendations following Riley’s death and noted that “Crown counsel thought there was sufficient cause for concern that a police investigation was instructed into the failure to produce prison records”.

The sheriff said in a judgment: “With the benefit of the relevant knowledge, the SRU staff would have identified that the (parole board) decision was likely to have a significant detrimental impact on Sarah such that she should be placed on the Talk to Me suicide prevention strategy. Had that been done, her death would have been avoided.

“This is an example of 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.”

The judgment said the prison was “not equipped” to deal with “three serious sets of issues” which Riley presented.

The sheriff added: “Sarah’s case had to be negotiated around the various rules, policies and strategies that had to be applied.

“The initial solution was to remove her from association, in the SRU. After some delay, the transgender policy was considered and the conclusion reached that Sarah should be transferred to the female estate.

“The authorities at Perth had very little influence over transfers which led to further delay. Her other problems were neglected in the meantime.”

After self-identifying, Riley initially lived as a woman at Castle Hunan open estate prison for men, and from March 2015 the Scottish Prison Service (SPS) recognised her protected status as a transwoman. In June 2015 she was transferred to all-female Cornton Vale Prison.

However Riley “encountered many difficulties with other prisoners”, self-harmed and was put in solitary confinement for three months, before being returned to Perth Prison after indicating she wished to live as a man.

In November 2015 Riley disclosed to a prison officer she was “being forced to stop the transition… and would be kept in segregation for a long time because SPS did not know or understand where she is best placed”, the FAI was told.

In December 2015, she “stated clearly that she wanted to live as a woman” and “was being punished for being transgender”, and was put on suicide watch.

Aged 26 in 2016, she adopted the name Sarah, moved to mainstream conditions in Perth Prison, and was assessed as meeting the criteria for three personality disorders.

After being released on parole in July 2018, Riley lived as a woman, but when she was recalled to prison in November, she was put in solitary confinement while discussions went on about moving her to the female prison estate, which she had concerns about, the judgment said.

Riley was remanded in Perth Prison on November 6, 2018 and placed in solitary confinement, according to the FAI judgment which said she was “kept in the SRU without legal authorisation for a period of about 18 days”.

A transgender case conference was convened on November 12, 2018 which heard Riley should be moved to Polmont Prison, however she said she “felt safe” in Perth Prison and “the staff knew her well”, according to the judgment.

Riley was then moved to another SRU on November 24 when the prison governor made an order under Rule 95 “to authorise Sarah’s removal from association for her protection as a trans woman”, the judgment said.

On December 21 2018, Riley told a nurse at Ninewells Hospital that “no-one was listening to her, she felt isolated and was having thoughts of taking an overdose”, the FAI heard.

Six days later, a mental health assessment was started by a nurse but left incomplete with no notes implemented into the system, and handwritten notes were later destroyed.

On January 8 2019, Riley attended a PBS Order of Lifelong Restriction Tribunal hearing within Perth Prison which staff “knew” had no realistic prospect of release on licence, and on the afternoon of January 11 she was given the outcome letter by a prison officer.

The sheriff’s judgment said: “The period Sarah would spend in the SRU was prolonged without an end in sight so long as there was no realistic prospect of transfer. This was not due to any misconduct by Sarah…

“There was no plan other than to wait and see if Sarah was more disposed to the proposal that she transfer to Polmont a few weeks after she had expressed strong opposition to that proposal for reasons based on her prior adverse experience in the female estate.

“The only option apparently being pursued after December 21 2018 was to hope that if Sarah was left… in the SRU for a few more weeks it might make her more amenable to the only transfer proposal on the table.”

The sheriff noted SPS HQ approved a Rule 95 application “without inquiry” from the prison governor which did not disclose that Riley had been in isolation since November 6, and “SPS HQ proceeded on the basis that the three-month period started 21 days after she was first placed in the SRU”.

On December 27, a further conference was held which noted Riley “had expressed no interest in being transferred to Polmont” but it was hoped with her “co-operation that the transfer issue could be resolved as soon as possible”, according to the judgment.

Riley was found to have consumed “potentially fatal” quantities of controlled drugs, leading to questions of whether the clinical decision to provide seven days of medication should have been reviewed following the Parole Board decision not to direct release.

Procurator fiscal Andy Shanks said: “The sheriff’s determination notes recommendations in relation to reasonable precautions that could have been taken to avoid Sarah’s death and identified learning to help avoid such incidents happening to prisoners with complex needs.

“My thoughts remain with Sarah’s loved ones at this difficult time.”

A Scottish Prison Service spokesperson said: “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.”

Justice Secretary Angela Constance said: “My deepest sympathies and condolences are with the friends and family of Sarah Riley after their tragic loss.

“I thank Sheriff di Emidio for his detailed determination. His recommendations will be given very careful and detailed consideration.

“It is absolutely crucial that both the Scottish Government and the SPS take the time to consider these recommendations in their entirety, set against the actions already taken to prevent and reduce suicides in custody.”