Numerous failures are identified by Sheriff Jonathan Guy in a recently published determination from the fatal accident inquiry into the death of Michael Charlton, who died by suicide at HMP Barlinnie in October 2019. 

This included three reasonable precautions, five defects in the Scottish Prison Service’s (SPS) system of working, nine detailed recommendations and six other facts relevant to the death. It is worth noting that the Inquiry took seven years to complete from the date of death.

The inquiry found that prison staff failed to conduct regular observations of Mr Charlton as required by the suicide prevention scheme when he had indicated to an officer that he intended to take his own life. 

It also found prison staff erroneously attributed suicide warning signs in Mr Charlton to intoxication. Recommendations included revising the prison suicide prevention policy, which an independent review commissioned by the SPS recommended in December 2025. Among other substantial defects in the system and facts that were relevant to the circumstances of his death included the lack of training of prison staff on the implementation of the MORS (the Management of Offender at Risk Due to Any Substance) policy. 

There have been at least 72 suicides in prison since Michael Charlton’s death, according to SPS published statistics.

Significantly, Sheriff Guy cited the recent opinion of the inner house Court of Session, authored by the lord president, Duncan v Lord Advocate [2025], specifically noting that “a wide power has been conferred on the sheriff to identify any precautions which could have been taken which might have avoided the death”.

Throughout the inquiry he adopted the approach set out in Duncan, noting that an identified precaution need not be the sole or principal cause of someone’s death.