Inquiry Under The Fatal Accidents And Sudden Deaths Inquiry (scotland) Act 1976 Into The Death Of John Perry
| Jurisdiction | Scotland |
| Judge | Sheriff L.D.R. Foulis |
| Neutral Citation | [2017] FAI 10 |
| Court | Fatal Accident Determinations (Scotland - United Kingdom) |
| Date | 07 April 2017 |
| Docket Number | B141/15 |
| Published date | 05 May 2017 |
SHERIFFDOM OF TAYSIDE CENTRAL AND FIFE AT PERTH
[2017] FAI 10
B141/15
DETERMINATION
BY
SHERIFF LINDSAY DAVID ROBERTSON FOULIS
UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRIES (SCOTLAND) ACT 1976
into the death of
JOHN PERRY
PERTH, 7th April 2017. The Sheriff, having considered all the evidence adduced, determines:-
1. In terms of Section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, that John Perry died at 12.28pm on 23rd January 2013 within Perth Royal Infirmary, Perth following his hanging himself in Cell B 1/4 within HMP Perth from the top of a bed by means of a ligature made from a shoe lace on 19th January 2013 between 2.26pm and 3.48pm.
2. In terms of Section 6(1)(b) of the said Act, that the cause of the death of John Perry was ligature pressure on his neck by a shoe lace.
3. In terms of Section 6(1)(b) of the said Act, that the cause of the said accident was the application of the ligature by Mr Perry round his neck.
4. In terms of Section 6(1)(c) of the said Act, that a reasonable precaution whereby the death of Mr Perry and the application of the ligature by him round his neck might have been avoided was Prison Officer Roderick Thomson placing a copy of the letter from Mrs Gilmartin, Procurator Fiscal depute, Perth, dated 16th January 2013 addressed to the Governor, HMP Perth in the prison medical records of Mr Perry and attaching a copy of said letter to the ACT2care booklet relating to Mr Perry which was duly completed on his admission to HMP Perth on 16th January 2013.
5. In terms of Section 6(1)(e) of the said Act, that other facts which are relevant to the circumstances of the death of Mr Perry were that Prison Officer Lee and Nurse Ian Duncan should have been appraised of the terms of the said letter, which constituted additional information as defined in the ACT2care reception risk assessment form, by Prison Officer Roderick Thomson before they carried out the Reception Risk Assessment and Health Care Risk Assessments of Mr Perry respectively on 16th January 2013.
6. In terms of Section 6(1)(e) of the said Act, that other facts which are relevant to the circumstances of the death of Mr Perry were that the Personal Escort Record relating to Mr Perry made no mention of his having been subject to constant observations during part of the period he was held in police custody on 15th and 16th January 2013 and there was no specific provision on the said form to note that he was subject to constant observations at certain times whilst in police custody.
7. In terms of Section 6(1)(e) of the said Act, that other facts which are relevant to the circumstances of the death of Mr Perry was that Doctor Mark Wallace was not provided with a copy of the Personal Escort Record relating to Mr Perry when he carried out his assessment of Mr Perry on 17th January 2013.
NOTE
[1] This Fatal Accident Inquiry into the death of John Perry following events at H M Prison Perth on 19th January 2013 took place on 29th and 30th October 2015,1st and 2nd February, 29th and 30th March, 16th 18th and 19th May, and 10th October 2016. Thereafter the parties were allowed time to lodge and intimate written submissions and I heard oral submissions on 21st December 2016. The parties’ written submissions are appended to this note. Their oral submissions are recorded at the end of the appendix. Mr Quither, Procurator Fiscal depute, presented the case for the Crown. The other parties represented were the deceased’s family, Tayside Health Board, the Prison Officers’ Association, Prison Officer Ian Duncan, the Scottish Prison Service, Doctor David Sadler, and the Chief Constable of Tayside Police, now Police Scotland. These parties were represented by Mr Williams, solicitor, Glasgow, Mr Stuart, advocate, Edinburgh, Mr Cahill, solicitor, Glasgow, Miss Docherty, solicitor, Glasgow, Miss Phillips, solicitor, Edinburgh, Miss Railton, solicitor, Glasgow, and Mr Reid, solicitor, Glasgow respectively.
[2] Evidence was led by the Crown from M/s Pauline McLaughlin, Police Sergeants James Aitken, and Michael Assenti, Detective Constables Aitken Coupar and Lesley Murray, Police Constable Alan Boyd, Reliance and G4S officers Mark Cooper and Catherine Lindsay, Mrs Charmaine Gilmartin, Procurator Fiscal depute, Prison Officers Graeme Appleby, Peter Lee, Roderick Thomson, David Langlands, Kevin Sclater, Derek Pirie, and Peter Ward, Social Worker Richard Geddes, Doctor David Sadler, Prison Nurses Ian Duncan, Catriona Baxter, and Gail Livingstone, Doctor Mark Wallace, Prisoners Jamie Morrison, Darren Byrne, and David Davidson, paramedic Amanda Storer, and M/s Lesley McDowall. M/s Dawn Wigley was called as a witness for Tayside Health Board and Chief Inspector Gordon Milne was called as a witness by the Chief Constable.
[3] The parties also produced a lengthy joint minute of agreement covering a number of issues. It dealt with the nature of the charges on petition upon which Mr Perry appeared on 16th January 2013 and documentation associated with the petition. It covered his appearance in court and his remand to HMP Perth. It covered his prison accommodation and prison routine. It covered his care in Perth Royal Infirmary after he was discovered in his cell on 19th January 2013, including details of the medical examination carried out and treatment administered. Finally, the joint minute covered the content of a handwritten note in his cell recovered on 19th January 2013, various photographs, the results of his post mortem, various documentary productions, recordings, DVDs of digital CCTV recordings, and the conclusions of a review carried out by the Scottish Prison Service after Mr Perry’s death. Copies were also agreed to be the equivalent of principals.
[4] Before I move to consider the evidence, submissions, and my determination, I would wish to make certain observations. It cannot be anything other than regrettable that Mr Perry died in January 2013 but evidence only commenced in this inquiry almost three years after he passed away. The matters which required to be determined in terms of section 6(1)(a) and (b) of the 1976 Act were straightforward. Whilst I appreciate evidence was led over ten days, there was no apparent difficulty in obtaining evidence from most of the witnesses. It accordingly was not immediately apparent why this inquiry could not have commenced earlier. Once started, I fully appreciate that a combination of court and representatives’ diaries can cause problems in a lengthy inquiry, nonetheless it is again regrettable that evidence was led over twelve months as opposed to being concentrated over a shorter period. In making these remarks I am also fully aware that I have taken some time to issue my determination. I regret this. Unfortunately the demands on shrieval time to produce reports in relation to criminal appeals and a judgement in a permanence proof have resulted in a delay on my part. Pressure upon court resources also results in dedicated writing days becoming something of a rarity nowadays.
[5] In considering my determination, the principal source of criticism is Mr Perry’s family. In Mr Williams’ written submissions, he focuses on three separate stages of the last few days of Mr Perry’s life. I consider that this approach is helpful. Accordingly, I am going to cover matters under three headings, events within the police station, events at court, and thereafter events at HMP Perth. In looking at the last stage, I consider that it is also appropriate to separate matters further. It seems to me logical that I consider events surrounding Mr Perry’s admission, his examination by Doctor Wallace, and events in B Hall separately. I also consider it appropriate that I examine the ACT2care procedure briefly as this procedure is relevant, apart from anything else, in considering the relationship between any acts and omissions which may have occurred at various stages and the death of Mr Perry. In all these events the presentation and demeanour of the deceased is significant and I consider that this is the first matter which requires to be considered.
[6] Mr Perry was clearly a person who had a number of issues. He had been an abuser of controlled drugs, particularly cannabis. His mother also described him as a binge drinker. She described him as being significantly under the influence of drugs when she saw him in Greenock in 2012. She described displays of paranoia in 2012 involving such as the fidelity of his girlfriend. Before he was remanded in January 2013, he commented to his mother that he was fearful. He had written on his right groin ‘I did not commit suicide.’ He was described as ranting. During Christmas 2012 he made comments to his mother such as inquiring how to knot a noose. He was convicted in 2004 inter alia of assault to severe injury and permanent disfigurement and was sentenced to three years detention. He was convicted of an analogous offence in 2010 and received a further sentence of imprisonment, this time for two years. He was convicted of other matters between 2004 and 2010 and was sentenced to imprisonment on another five occasions. One of these convictions in 2008 was a contravention of section 4(3)(a) of the Misuse of Drugs Act 1971. His brother suffered from mental health problems. His father had died in 2008. According to the information M/s McLaughlin gave to Mr Geddes, his father had committed suicide. When the deceased was apprehended and the police contacted her, she made no mention of any concerns she had about her son to the officers. It cannot be overlooked that his mother had significant knowledge regarding his behaviour in the year prior to his death. The authorities who dealt with Mr Perry from 15th to 19th January 2013 were unaware of the great majority of these matters, the only disclosure by M/s McLaughlin being her telephone call with Mr Geddes.
[7] On 18th January 2013 there were five telephone calls from Mr...
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