Handling of deaths in prison

Justice Secretary announces independent expert review.

An independent expert review of the handling of deaths in prisons is being established.

The review will identify areas for improvement to ensure appropriate and transparent arrangements are in place in the immediate aftermath of deaths in Scottish prisons. It will also cover deaths of prisoners in NHS care and will report next summer.

The independent review will be led by Wendy Sinclair-Gieben, Her Majesty’s Chief Inspector of Prisons for Scotland with additional expertise and assurance provided to her by Professor Nancy Loucks, Chief Executive of Families Outside, a national charity which works on behalf of families affected by imprisonment.

The review will examine the operational policies, practice and training in place within the Scottish Prison Service and NHS relevant to deaths of prisoners.

It will draw on human rights expertise and will also consider the experiences of bereaved relatives. It will seek their views on preventative approaches which could better enable families to raise concerns regarding the wellbeing of loved ones in prison.

The review is intended to complement current arrangements for the investigation of deaths in custody and the holding of Fatal Accident Inquiries, which are the responsibility of the Lord Advocate acting independently of any other person.

Justice Secretary Humza Yousaf has written to the Parliament’s Justice and Health committees to provide the Terms of Reference for the review.

He said:

“The safe treatment and mental health of all those in custody is a priority for Scotland’s prisons, which care for people with higher levels of risk and vulnerability than the population as whole.

“My thoughts are with every family tragically bereaved by a death in prison custody and I fully understand the desire for answers following the death of a loved one. This review will inform improvements to ensure that all processes and communication with families are as open and transparent as possible.

“Scotland’s justice system is committed to protecting the human rights of all who pass through it and a Fatal Accident Inquiry is mandatory following all deaths in custody.”

The Terms of Reference for the Independent Review Into the Handling of Deaths in Prison Custody are as follows:

The purpose of the review is to identify and make recommendations for areas for improvement to ensure appropriate and transparent arrangements are in place in the immediate aftermath of deaths in custody within Scottish prisons and YOIs, including deaths of prisoners whilst in NHS care.  The review will include consideration of deaths of prisoners whether on remand or following conviction.

The review will:
• examine the policies, training and operational procedures in place within the Scottish Prison Service (SPS) and NHS relevant to deaths in custody.  This will include arrangements in the immediate aftermath of a death in custody, including the identification and preservation of relevant evidence and the roles and responsibilities of management and individual staff involved in such incidents
• examine the arrangements within the SPS and NHS for the immediate Critical Incident Response & Support (CIRS) process and the subsequent joint Deaths in Prisons Learning, Audit & Review (DIPLAR) process.  The DIPLAR process is intended to enable areas for improvement and potential learning to be identified following a death in prison custody (including where the death occurs in hospital) in advance of an FAI.  The review should examine the consistency and differences between previous FAI determinations and recommendations and learning arising from the DIPLAR process
• examine the openness and transparency of arrangements following a death in custody, including communication with family members
• examine the support arrangements in place for families, SPS and NHS staff and others affected by deaths in custody
• examine the views of families impacted by a death in prison custody including preventative approaches which can enable families to raise concerns regarding family members in prison

The review will draw on evidence from other previous reports and reviews within and external to the SPS and NHS.  This should include consideration of the development of the DIPLAR process and relevant findings and recommendations arising from the published reviews by Dr Briege Nugent and the Expert Review of the Provision of Mental Health Services for Young People at HMP YOI Polmont (May 2019).

The Lord Advocate is the independent head of the system for the investigation of sudden and suspicious deaths and COPFS carry out that work on his behalf.  The process for any potential criminal investigation or the investigation of deaths by COPFS are outwith the remit of the review.  The independent Inspectorate of Prosecution in Scotland carried out a thematic review of COPFS arrangements for Fatal Accident Inquiries in 2016, and completed a follow up review, which included arrangements for FAIs arising from deaths of young people in custody, in 2019, both with relevant recommendations.

The review will not consider or comment on the circumstances of individual deaths in custody which are the subject of on-going investigation by COPFS or have not yet been the subject of an FAI or where there has been a FAI, no determination has yet been issued.

It will not consider the deaths of people in police custody or following formal release from prison.


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