A teenager was “screaming for support” with his mental health problems before his death in a young offenders’ institution, a court has heard.
Liam Kerr was self-harming and attempted suicide at Polmont YOI, near Falkirk, in January 2017.
The 19-year-old, from Paisley, died in hospital less than a week later.
A fatal accident inquiry heard that staff did not agree with mental health reports which said his previous behaviour was not psychotic.
Mr Kerr was in Polmont on remand over allegations that he had robbed a sandwich shop in Paisley.
The inquiry heard he had been diagnosed on a previous admission as suffering from drug-induced psychosis and was said to have “complex” mental health needs.
The teenager tried to take his own life only hours after being seen by an NHS psychiatrist who ruled out an immediate transfer to a psychiatric ward.
Polmont warder Brian Ward, 48, said officers in the unit where Mr Kerr was being held were “totally disheartened” by the feedback they got from mental health services.
‘Shouting and incoherent’
Mr Ward told the inquiry at Falkirk Sheriff Court: “He was shouting all the time, throwing food over his cell, saying there were other people in his cell with him when there weren’t, screeching and shouting all night.
“He appeared to be speaking to his gran every day. He rubbed toothpaste over his body and head, and was breaking into what appeared to be an Irish accent. His shouting was incoherent.
“It was 24 hours a day that Liam was behaving that way.”
He added: “He was seen by a psychiatrist and a psychologist and the feedback we were given was that it was behavioural, not psychotic. We didn’t agree with that.
“Myself and my colleagues were totally disheartened with the feedback we got for him. We were trying to deal with a person, care for them, and all our experience went for nothing.”
Psychiatric nurse Brian Leech told the inquiry he had been on duty the weekend before Mr Kerr’s attempted suicide when he was called to see him in the exercise yard.
Mr Leech said: “He was shouting, not making any real sense as far as I could see, and pacing about the yard.”
He added that he managed to settle the teenager down and returned him to his cell, which was “a mess”.
The next day he saw him again, and found him “shouting and screaming”. Mr Leech said he was placed on medication to help him sleep, and he arranged for the teenager to be seen by another nurse the next day.
He said: “I was thinking, if he gets a good night’s sleep on the Sunday night, maybe he’d be different on the Monday. But apparently he wasn’t.”
‘Not at suicide risk’
Mr Leech said he had not activated the Scottish Prison Service’s suicide prevention protocol, known at that time as Act To Care, as Mr Kerr was not presenting any signs that he was at risk of self-harm or suicide.
The following week, Mr Leech said he was present when Mr Kerr was seen by NHS Forth Valley consultant psychiatrist Dr Rosa Serrano.
He said: “Liam was totally different from when I saw him at the weekend. He seemed a lot worse. He wasn’t making any sense, and you couldn’t bring him back to talk to him rationally.”
He said he understood that the psychiatrist’s view was that Mr Kerr’s condition was “deteriorating” and he was placed on anti-psychotic medication.
Mr Leech said: “The view of the doctor was that hospitalisation wasn’t necessary at that point. The plan was to see if the anti-psychotic medication would work.”
The inquiry later heard from Mr Kerr’s brother, Sean, who said there had been a “lack of liaison” about the teenager’s history of mental illness.
Mr Kerr, 28, said: “Liam wasn’t himself. There were reports that he was screaming for support.
“There should have been an action plan, and I’m struggling to understand why there was no referral to the suicide prevention team.”
The inquiry, before Sheriff Derek Livingston, continues.
Last year, Justice Secretary Humza Yousaf ordered an independent review of mental health services at Polmont.
It followed the deaths of a series of teenagers, which sparked public and parliamentary demands for an over-reaching probe into how vulnerable inmates are treated.