A manager at the young offenders’ institution where two young people died within months of each other said he had to “live with” the fact he decided a 16-year-old boy was not suicidal, who went on to take his own life.

A fatal accident inquiry at Falkirk Sheriff Court is examining the circumstances of the deaths of Katie Allan at Polmont Young Offenders Institution in June 2018, and William Brown, 16, also known as William Lindsay, who took his own life at the facility four months later.

Mr Brown, who had been in care repeatedly, was found dead in his cell on October 7, three days after being admitted as there was no space in a children’s secure unit, having walked into a police station with a knife.

Ms Allan, a student at Glasgow University, was found dead in her cell on June 4 while serving a 16-month sentence for drink-driving and causing serious injury by dangerous driving.

On Thursday the inquiry heard evidence from John Dowell, 54, a manager of the unit where Mr Brown was being held in October 2018.

Katie Allan and William Lindsay inquiry
The fatal accident inquiry is taking place at Falkirk Sheriff Court (Andrew Milligan/PA)

He said Mr Brown was the only prisoner he had lost in what was then more than 20 years of experience within the Scottish Prison Service (SPS).

Mr Dowell said he had held “hundreds” of case conferences, including the one which took place to make the decision that Mr Brown be taken off a suicide prevention programme, throughout his career.

He added: “I have had hundreds of case conferences and I have only lost one prisoner and that was William Brown.

“I have always done it methodically.”

Mr Dowell said Mr Brown looked “relaxed” during the case conference and that he “firmly believed” the teenager was not suicidal at the time.

Mr Dowell added: “I have had to live with the fact that I thought he wasn’t suicidal, and he went on to the Saturday and committed suicide.

“I have had to live with that for five years.”

Advocate depute Leanne Cross asked Mr Dowell if he had assessed the information at the case conference properly.

Mr Dowell said: “Yes.”

Later Mr Dowell was questioned by Mark Stewart KC, acting for William Brown Snr, Mr Brown’s father, relating to the content of Talk 2 Me training, which was the suicide prevention scheme under which Mr Brown had been placed on arrival at Polmont.

Mr Dowell told Mr Stewart he had not looked at the documentation that had come in with Mr Brown.

Mr Stewart asked: “Do you accept that you made a mistake?”

Mr Dowell replied: “In hindsight, yes I made a mistake.”

Later, an addictions worker at Polmont told the inquiry that Mr Brown had told her he “wouldn’t be telling anyone again” if he was feeling suicidal.

Tara Duthie, 57, said Mr Brown had told her he had “gone to a police station with a knife with the intention of killing himself”.

Ms Cross asked if there was anything about his comment that she would consider to be significant.

Ms Duthie replied: “That he wouldn’t tell anyone if he was feeling suicidal.”

The addiction worker, who has since moved on from Polmont, said she passed her concerns to mental health nurse Brian Leitch at a handover meeting at about 1pm on Friday October 5, 2018.

She said Mr Leitch had told her Mr Brown had been taken off the Talk 2 Me programme.

She added: “I was surprised, I did have concerns but (Mr Leitch) was a mental health nurse with decades of experience. I didn’t feel it was my place to question his decision.”

She was unable to add her notes about Mr Brown’s comments to the Polmont health centre’s computer system, saying there was a shortage of computers, and only updated her notes on Monday, October 8 – the day after Mr Brown had been found dead in his cell.

Earlier on Thursday, prison officer Natalie Cameron, 34, told the inquiry that the staff who had dealt with Mr Brown when be came into custody had “no concerns” about him and that they did not feel he was “at risk” of suicide.

Mr Stewart asked her why she had not asked to see any paperwork in relation to Mr Brown, ahead of his first case conference where the decision was made.

Ms Cameron said: “I’m sorry, I don’t really have an answer to that.

“I didn’t feel like I had to look into it any more.”

Ms Cross asked Ms Cameron what her decision would have been had she seen the paperwork, which said Mr Brown had a previous history of mental health issues and suicidal thoughts and had previously attempted suicide in a secure unit.

She said: “My decision would probably be different.”

The inquiry, before Sheriff Simon Collins KC, continues.