FAI DETERMINATION SUMMARIES

Fatal Accident Inquiries (FAIs) are held following a death in the workplace or in cases which give rise to reasonable suspicion. They are usually held in the sheriff court, but may be held in other premises when appropriate. Summaries provide the main findings in order to assist understanding and may be published in cases where there is wider public interest. They do not form part of the reasons for the findings.

The full Determination published on the Scottish Courts and Tribunals website is the only authoritative document.

Fatal Accident Inquiry in to the death of Sarah Jane Riley

Nov 4, 2025

Sheriff Pino Di Emidio has made eight recommendations in his determination following a Fatal Accident Inquiry into the death of Sarah Jane Riley at HM Prison Perth on 12 January 2019.

Warning: this summary and FAI determination discusses suicide. If you are affected by what is discussed in it, help and support is available from Samaritans by calling 116 123 or visiting samaritans.org.
Introduction

Sarah was found in her cell in the Separation and Reintegration Unit (SRU) at the Prison and pronounced dead at 08:15 hours. Her cause of death was asphyxiation by a plastic bag.

Sheriff Di Emidio has ruled that there were no precautions which could reasonably have been taken which might realistically have resulted in the death being avoided. However, the Sheriff found there was a system of working which may have contributed to the death. In particular there was no system in place to allow risk assessments for Order for Lifelong Restriction prisoners to be used to identify any risks to themselves as well as a risk to others, although this could be easily done.

The Sheriff determined that had this been done and communicated to the SRU staff working with the deceased, they would have had a clearer understanding of what she was going through and the likely effect of the adverse Parole Board for Scotland (“PBS”) that she received shortly before she was locked in her cell for the night on 11 January 2019.

The Sheriff identified other facts which he deemed to be relevant to the circumstances of the death.

a. None of the staff in the SRU had knowledge of the impact of the deceased’s Order for Lifelong Restriction sentence and of the recall on her.

b. There was a failure to deal promptly with the proposed transfer of the deceased to a prison in the female estate.

c. The deceased was removed from association (separated from the general population) upon arrival at Perth Prison for the entire period up to her death.

d. There was no legal warrant for the first 18 days in which the deceased was removed from association. When authorisation was sought to keep the deceased removed from association the true state of facts as to the lack of legal warrant to keep her in the SRU was not disclosed to Scottish Prison Service (“SPS”) HQ.

e. A personal officer was not appointed for the deceased who was a vulnerable prisoner despite a request by the prison psychologist.

f. Tayside Health Board (“THB”) staff failed repeatedly to attend Transgender (“TSG”), OLR and other case conferences held in respect of the deceased.

g. There was delay by THB staff in commencing a Mental Health assessment of the deceased. The assessment commenced after 53 days and was not completed. The records were not preserved.

Sarah Riley was a transgender woman. She is referred to as “Sarah” in this determination as that is consistent with how she was known in the various public records relating to her in the last few years of her life.

Background

In December 2007, Sarah appeared on Petition at Perth Sheriff Court and was remanded in custody at Perth Prison. On first arrival at Perth Prison, she was assessed as suicidal. On 27 March 2008, Sarah pleaded guilty at a First Diet. After hearing the narrative, the Sheriff continued his remand and remitted the case to the High Court of Justiciary for sentence.

On 8 December 2008 Sarah was sentenced at the High Court of Justiciary. An Order for Lifelong Restriction was imposed. The punishment part was specified as 2 years 8 months detention (backdated to 21 December 2007). Whilst serving the sentence and awaiting a decision to release her on licence, Sarah was accommodated at Polmont YOI, Cornton Vale Prison, Greenock Prison, Perth Prison and Castle Huntly Prison.

Sarah was refused parole in 2011 and 2014.

Around February 2015, Sarah declared her wish to live as a female and began living as a female in adult male open conditions. SPS recognised her protected status as a trans woman from 9 March 2015. On 26 June 2015, Sarah transferred to Cornton Vale Prison. The transfer to the female estate was not successful and Sarah encountered many difficulties with other prisoners.

On 31 July 2015, the prison authorities became aware that Sarah had suicidal ideation. She was placed in segregation under Rule 95 after this and remained in the Separation and Reintegration Unit (SRU) for the remainder of her time at Cornton Vale.

During 2015 Sarah required medical attention on two occasions following self-harm incidents in response to being told she would be returned to the male estate.

On 28 October 2015 Sarah was returned to Perth Prison after indicating she would live as a male. She was removed from the suicide prevention regime then used by SPS in November.

She expressed anger and upset at the way she had been treated at Cornton Vale and claimed she was being forced to stop the transition from male to female. During her time in custody Sarah was subjected to lengthy periods of isolation.

Sarah was again refused parole in November 2015. In December she stated clearly that she wanted to live as a woman and believed she was being punished for being transgender.

In March 2016 she stated that she wished to be referred to as Sarah and in May she was moved to the mainstream conditions of Perth Prison.

The Risk Management Team at Perth carried out an assessment of Sarah using the International Personality Disorder Examination (IPDE) and Psychopathy Checklist Revised (PCL-R).

This work was completed in June 2016 when Sarah was 26 years old. It would not have been appropriate to carry out these assessments at a younger age.

The conclusion reached was that she met the diagnostic criteria for Paranoid Personality Disorder, Emotionally Unstable (Borderline Type) Personality Disorder and Anxious Personality Disorder. There were also features of dissocial and schizoid personality disorders.

Sarah was again refused Parole in 2016 and 2017 but was transferred to the open estate in October 2017 and to Castle Huntly Prison with some home leave at Anchor House, Perth.

In July 2018 the Parole Tribunal decided to direct her release and she was released to Anchor House on licence. During the time she was residing at Anchor House, Sarah spoke regularly about the OLR and stated she would end her life if she was recalled to prison.

On 5 November 2018, the Parole Board, following consideration of a Throughcare Licence Breach Report, revoked Sarah's licence and this was communicated to the Scottish Ministers Community Licence Team. This followed several incidents which caused concern to the social workers monitoring her. The Community Licence Team specified Perth as the recall prison. Perth was a male prison at the time.

On 6 November 2018, Officers of the Police Service of Scotland traced Sarah. They then arrested her and transported her to Perth Prison. Sarah was assessed as presenting well and there was no apparent risk at that time. Although Sarah was lawfully imprisoned in Perth Prison, she was kept in the SRU without legal authorisation for a period of about 18 days, from 6 to 24 November 2018.

The SPS Policy specified that the first TSG case conference should take place within 24 hours of the prisoner’s arrival at the receiving prison.

A TSG case conference to consider Sarah’s case was convened on 12 November 2018. This was attended by the Equality and Diversity Manager from SPS HQ. This was an advisory role which covered trans prisoners across the whole prison estate.

Concern was raised that Sarah had been returned to Perth Prison as she had been living in the community as a woman for some time. The Equality and Diversity Manager had advised that the then current SPS TSG Policy required that Sarah should be transferred to the female estate. Sarah expressed some concern about moving to a female prison due to the problems she experienced when she was placed in Cornton Vale. She stated she felt safe in Perth as it was familiar, and staff knew her well.

The SPS staff in attendance agreed that there should be an application under Rule 95 to authorise Sarah’s removal from association for her protection as a trans woman. Despite this no action to progress an application was taken until 24 November 2018.

In follow up correspondence, the Equality and Diversity Manager confirmed to the Deputy Governor that he expected that the transfer to happen within a few weeks.

Following the TSG case conference, the officials at Perth proceeded on the basis that Sarah would be transferred. Sarah said she did not want to go to Polmont or Cornton Vale due to past experiences.

As Sarah was an OLR prisoner, the Risk Management Team at Perth began work to update their assessment of the risk she posed to others. The information gathered was also relevant to the issue of the risk she posed to herself, but no element of this information was shared with staff in SRU. She was a vulnerable prisoner being held in segregation for reasons of safety and not due to any misbehaviour on her part.

The appointment of a personal officer was an important safeguard. The need for a personal officer had been noted at case conferences and by the prison psychologist, but no action was taken.

The need for a mental health assessment was noted on more than one occasion but delayed and never completed.

Around 12 December 2018, following a formal meeting at SPS HQ, the Deputy Governor of Perth discussed Sarah’s proposed transfer with her opposite number at Edinburgh Prison. Edinburgh Prison refused to take Sarah as there were already too many TSG prisoners held there.

An attempt later the same month to secure a transfer to another prison was not successful. The processes then in place meant that there would be no scrutiny at SPS HQ of the failure to secure a transfer for a period of 3 months from the time she was officially placed in segregation.

On 11 January 2019 Sarah received notice that she had been refused parole and would have to remain in closed prison conditions for at least 12 months. No steps were taken to implement the suicide prevention strategy in respect of her.

On 11 January 2019, Sarah was secured within her cell for the evening at approximately 1715 hours. On 12 January 2019, during morning checks, officers in the SRU found Sarah unresponsive in her cell at around 0809 hours. Her life was pronounced extinct at 0815 hours on 12 January 2019.

Shortly after her death, SPS changed its procedures so that the suicide prevention strategy is implemented at the point when a prisoner like Sarah receives notification that early release has been ruled out.

In around February 2024, SPS published its new Policy for the Management of Transgender People in Custody. In around February 2024 SPS also published Operational Guidance designed to support the Policy for the Management of Transgender People in Custody.

If Sarah had been recalled to prison at a time when the 2024 Policy and supporting Operational Guidance were in force, it is likely that the application of the new policy would have resulted in Sarah being sent to a male prison.

Recommendations

The Sheriff made the following recommendations.

Dissemination of psychological formulation of OLR prisoners’ risk to themselves.

1. The Scottish Ministers and SPS should consider (a) establishing a system in respect of prisoners who have been sentenced to an OLR to allow for a psychological formulation focussed on the prisoner’s risk to themselves, based on the information already available from the risk management plan (“RMP”), to be prepared and shared with the prisoner’s personal officer and other SPS and NHS staff working with the prisoner’s personal officer on a regular basis; (b) providing training to SPS and NHS staff on the impact of OLR sentences on prisoners.

2. Training should be provided to SPS and NHS staff on OLRs and the impact of these sentences on prisoners.

Prompt consideration of whether a transfer should occur

3. The Scottish Ministers and SPS should consider (a) making a requirement that an urgent case conference should take place within 7 days of the arrival of a recalled prisoner who is within the scope of the current TSG policy to decide if the prisoner requires to be transferred to another prison; (b) specifying that the case conference should be chaired by a person of at least the rank of Deputy Governor; (c) the person chairing the case conference should be required to take action to secure that any decision as to transfer is actioned promptly; (d) the chair should within 7 days submit a report to SPS HQ detailing the reason for the decision of the case conference; and (e) the report should be considered forthwith by the most senior person on duty at the time it is received at SPS HQ.

Review of decisions to remove OLR or TSG prisoners from association for safety reasons

4. Where an OLR or a TSG prisoner has been removed from association for more than 30 days for their safety, the Scottish Ministers and SPS should consider requiring that there should be an urgent high-level SPS HQ review at least at deputy governor level based on full reporting of the circumstances that has resulted in removal from association.

Disclosure to SPS HQ where a prisoner has been removed from association without legal warrant

5. Where a prison has removed a prisoner from association without the prison staff having initiated the Rule 95 process timeously, the Scottish Ministers and SPS should consider making a requirement that the local prison should disclose the fact that the prisoner has been held in segregation without legal warrant to SPS HQ forthwith, and provide an explanation for the failure to apply within the correct timescale.

Obligation to appoint a personal officer to an OLR or TSG prisoner

6. The Scottish Ministers and SPS should consider making a requirement that any request by a prison psychologist for the appointment of a personal officer to an OLR or TSG prisoner must be actioned within 7 days at Deputy Governor level.

Attendance at successive case conferences by NHS staff

7. The Scottish Ministers and SPS should consider making a requirement that: (a) a record should be kept of non-attendance by NHS staff at case conferences and the record monitored; and (b) if 2 successive case conferences are missed, this should trigger an obligation that a suitably experienced member of NHS staff must attend the next case conference.

Mental Health Assessment of OLR and TSG prisoners recalled from licence

8. The Scottish Ministers and SPS should consider making a requirement that when the need for a mental health assessment is identified on reception at prison or at a Case Conference or requested by a recently recalled OLR or TSG prisoner such an assessment should be commenced within 7 days.

The full Determination is available on the Scottish Courts and Tribunals Service website and is the only authoritative document.