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21 May 2019, 15:29 | Updated: 21 May 2019, 15:30
A review of mental health provision at a young offenders institution where two people took their own lives has found the "risks and vulnerabilities" of some inmates are not given enough attention.
The report on HMP YOI Polmont also found "systemic inter-agency shortcomings" of communication and information exchange across justice inhibit the management and care of young people entering and leaving the institution.
A review of mental health services for young people in custody was ordered by the Scottish Government following the death of Katie Allan, 21, and 16-year-old William Lindsay, who took his own life at Polmont 48 hours after being sent there on remand.
The report found being traumatised, being young, being held on remand and being in the first three months of custody increases the risk of suicide.
It found there is a lack of proactive attention to the needs, risks and vulnerabilities of those on remand and in the early days of custody, and highlights "the powerfully negative effect of social isolation".
The HM Chief Inspector of Prisons report makes more than 80 recommendations, including that social isolation, a "key trigger for self-harm and suicide", should be minimised, with a particular focus on those held on remand and during the early weeks in custody.
It also said a bespoke suicide and self-harm strategy should be developed by the Scottish Prison Service and NHS Forth Valley for young people that builds on the strengths of the existing framework.
Justice Secretary Humza Yousaf said: "We take the mental well-being of people in prison very seriously and while the numbers of suicides by young people in custody are small, no death should be regarded as inevitable.
"Any suicide in custody is a tragedy that has a profound effect on family and friends, as well as prison staff, and my thoughts are with all those who have lost loved ones to suicide.
"Both the mental health review and routine inspection report highlight the hard work, compassion and dedication of frontline prison and healthcare staff who provide opportunities and support to young people in custody every single day.
"That dedication is clearly evidenced in the Chief Inspector's finding that Polmont is a 'leading edge' prison where there are respectful relationships between staff and the people in its care and an impressive range of support offered to young people."
He added: "The report contains 80 recommendations and we are clear that improvements can and should be made.
"We will give the report and recommendations full and detailed consideration."
Katie's parents Stuart and Linda Allan, together with lawyer Aamer Anwar, met the Justice Secretary last year to discuss the issue.
Mr Yousaf said the Scottish Government would work with the Scottish Prison Service, NHS and other partners to consider further action in light of the review.
The Scottish Prison Service (SPS) said the safety and well-being of everyone in its care continues to be a priority and work is already under way to strengthen the support available.
A spokesman said: "The Scottish Prison Service takes all instances of self-harm and threats to self-harm very seriously and we constantly review our processes to ensure those at risk are identified and supported effectively."