Death in Prison Custody – Action Plan – Update June 2026

Progress on Recommendations

Key theme: Family contact with prison and involvement in care

Recommendation 1.1

Owner: Scottish Government

Progress made: Recommendations 1.1 and 3.4 are being considered jointly by the Scottish Government and remain in progress. Work is underway to explore whether a single framework for a system-wide, family-informed review of deaths in custody could be supported through the National Oversight Mechanism (NOM), with the aim of helping to prevent future deaths. A more detailed update on the scope of this work, including what can and cannot be taken forward through the NOM, will be provided at the next meeting in December.

Next key actions: The Scottish Government to provide an update on recommendations 1.1 and 3.4 for the December meeting.

Recommendation 1.2

Owner: NHS (to lead) and SPS

This recommendation has been implemented.

Update: The NHS Prison Care Network continues to support delivery through the Deaths in Custody Support Toolkit, with implementation measures monitored on a six‑monthly basis. Healthcare Improvement Scotland (HIS) has noted consistent implementation of the Toolkit as an area of good practice, and Version 2.0 has now been circulated with minor updates.

Recommendation 1.3

Owner: SPS

This recommendation has been implemented.

Recommendation 1.4

Owner: SPS (to lead) and NHS

This recommendation has been implemented.

Key Theme: Policies and processes after a death

Recommendation 2.1

Owner: NHS (to lead) and SPS

This recommendation has been implemented.

Update: Confirmation of death training uptake remains high across healthcare staff, with arrangements in place to ensure new staff complete training where required.

Recommendation 2.2

Owner: SPS

This recommendation has been implemented.

Recommendation 2.3

Owner: NHS (to lead) and SPS

This recommendation has been implemented. See update at 2.1.

Recommendation 2.4

Owner: SPS

This recommendation has been implemented.

Recommendation 2.5

Owner: SPS, NHS and SG

This recommendation has been implemented.

Update: People under 18 years old are no longer placed in Young Offenders Institutions and are now located in secure accommodation operating under child‑centred, UNCRC‑compliant care regimes, supported by national standards such as the Secure Care Pathway and Standards and embedded policy requirements within the Scotland Excel framework. Child friendly policies are monitored and assured through a multi‑layered regulatory framework, including Care Inspectorate registration and annual inspections, workforce regulation by the Scottish Social Services Council, and compliance with national contract specifications. Additional oversight is provided through Scottish Government leadership, regular operational engagement with providers, and formal reporting mechanisms for significant incidents and deaths, ensuring that children’s rights, safety and wellbeing are consistently upheld in practice

Key theme: Family contact and support following a death

Recommendation 3.1

Owner: SPS

This recommendation has been implemented.

Recommendation 3.2

Owner: SPS (to lead), NHS and the COPFS

Update: This recommendation is in progress. SPS is undertaking a gap analysis of current communication processes, with outputs expected to inform prioritised actions and timelines (around September 2026). A review of the Family Support Booklet is nearing completion, incorporating stakeholder input (including NHS, Families Outside and the Family Reference Group). A Bereavement Care Short-Term Working Group has been established to develop a draft framework and improve consistency of bereavement support. NHS continues to support improvements through trauma‑informed training and the Deaths in Custody Support Toolkit. Variation in investigation processes across NHS Boards has been identified, and a mapping exercise is underway to improve consistency.

Next key actions: SPS to complete gap analysis and define prioritised actions and delivery timelines, publish the updated Family Support Booklet and share the recommendations of the Short-Term Working Group on Bereavement Care.

Recommendation 3.3

Owner: NHS (to lead) and SPS

This recommendation was implemented.

Update: Families are supported through the Family Support Booklet. Monitoring is included in the QI measures.

Recommendation 3.4

Owner: SPS, NHS and Scottish Government

Progress made: Please see recommendation 1.1 for an update.

Key theme: Support for staff and other people held in prison after a death

Recommendation 4.1

Owner: NHS (to lead) and SPS

This recommendation has been implemented.

Update: SPS confirmed that a Post Trauma and Resilience (PT&R) policy is in place to ensure staff affected by traumatic incidents are identified and supported. The Senior Leader Wellbeing Programme is in place, combining group resilience sessions with one‑to‑one support, with positive uptake. NHS continues to embed trauma‑informed practice through training, Personal Development Plans and the Deaths in Custody Support Toolkit.

Recommendation 4.2

Owner: NHS (to lead) and SPS

This recommendation has been implemented.

Update: NHS has embedded trauma‑informed support through the Deaths in Custody Support Toolkit, including trauma‑informed training, wellbeing guidance and regular one‑to‑one welfare checks with line managers, particularly following deaths in custody. Training expectations are incorporated into Personal Development Plans to ensure consistent uptake. SPS has finalised its Post Trauma and Resilience (PT&R) policy, supported by guidance, resources and a dedicated SharePoint portal, with rollout underway. In addition, the Senior Leader Wellbeing Programme is established and showing positive early engagement, combining structured development sessions with access to confidential one‑to‑one support. Monitoring and evaluation arrangements are in place, including HR-led evaluation of the PT&R implementation and formal evaluation of the leadership programme.

Recommendation 5.1

Owner: SPS (to lead) and NHS

This recommendation has been implemented.

Update: Families are informed about DIPLAR and SAER within the revised Family Support Booklet. The implementation is monitored by the Quality improvement measures.

Recommendation 5.2

Owner: SPS (to lead) and NHS

This recommendation has been implemented.

Update: All relevant information is available in the revised Family Support Booklet and the Toolkit.

Recommendation 5.3

Owner: SPS

This recommendation has been implemented.

Recommendation 5.4

Owner: SPS

This recommendation has been implemented.

Progress on Advisory Points

Advisory Point 1

Owner: Scottish Government

Update: This Advisory Point is in progress. The Scottish Government confirmed that the Family Advocacy Service specification could not be amended to include this function. Further work is underway to determine whether this Advisory Point remains implementable.

Next key actions: Scottish Government to provide an update on Advisory Point 1 ahead of the December meeting.

Advisory Point 2

Owner: SPS

Update: This Advisory Point is in progress. Initial review led by SPS found that bedside alarms alone would not sufficiently address risks. Following FAI recommendations work is underway to consider digital solutions and wider cell environment changes and learning considered. The Signs of Life pilot has progressed, with further testing and evaluation ongoing, and final reporting is expected to be available by December 2026. A short-life working group is reviewing emergency response processes across SPS, NHS and the Scottish Ambulance Service.

Next key actions: SPS to complete pilot phases and evaluation and provide a further update ahead of the December meeting.

Advisory Point 3

Owner: SPS (to lead) and NHS

Update: This Advisory Point was implemented. SPS has confirmed that processes are in place to ensure relevant information from others in custody can be considered through the DIPLAR process, with oversight provided through routine completion checks and follow‑up on any non‑compliance. A DIPLAR review will provide further assurance and inform any necessary improvements. Within NHS, it is recognised that changes to the SAER framework are out of scope for the Prison Care Network. However, wider standardisation work is being progressed through the revised National Framework for Reviewing and Learning from Adverse Events in NHS Scotland, which includes expectations around broader participation.

Advisory Point 4

Owner: SPS (to lead) and NHS

This advisory point has been implemented

Advisory Point 5

Owner: SPS (to lead) and NHS

This advisory point has been implemented.

Update: The necessary information is available within the NHS Death in Custody Support Toolkit.

Advisory Point 6

Owner: SPS

This advisory point has been implemented.

Update: Ongoing assurance is provided through the DIPLAR process, supported by a scheduled DIPLAR review, which will inform any potential changes. In addition, the SPS Health Team undertakes checks to ensure that all DIPLARs are completed and that any non‑compliance is identified and followed up through feedback mechanisms.