Death in prison custody: action plan - updated August 2024

Death in Prison Custody – Action Plan – Update August 2024

Overview

The Independent Review of the Response to Deaths in Prison Custody was published in November 2021. The review made one key recommendation, nineteen other recommendations and six advisory points. We accepted all the recommendations made by the review in principle.

Since the 2021 report, the Scottish Government and partners have progressed a variety of actions on the recommendations. This page provides an update of the progress following the Deaths in Prison Custody Action Group (DiPCAG) August 2024 meeting from the Scottish Government and partners including Scottish Prison Service (SPS), Crown Office and Procurator Fiscal Service (COPFS) and the NHS.

Progress on recommendations

Theme: Key Recommendation

Recommendation 1

Owner: Scottish Government

Progress made: The second pilot of the draft investigative process took place on the 18th and 22nd of March 2024. The pilot was based on a slightly more complicated death which meant that the investigative process could be tested under different circumstances. Following the conclusion of both pilots (September/October 2023 and March 2024), a thorough evaluation took place. All those involved in the pilots took part and contributed to the evaluation process. A roundtable event was held on 8 August 2024 to consider the evaluation of the process which would aim to meet the key recommendation.

Next key actions: The outcomes of the Roundtable discussion will be considered by Scottish Government, including an options appraisal and costing considerations. A briefing will go to the Cabinet Secretary on potential ways forward.

Key theme: Family contact with prison and involvement in care

Recommendation 1.1

Owner: Various – Healthcare Improvement Scotland (HIS), NHS boards, the Care Inspectorate, National Suicide Prevention Leadership Group, His Majesty’s Inspectorate for Prisons in Scotland (HMIPS) and Scottish Government

Progress made: JAS' had intended to finalise the second report by end of summer but a number of issues have impacted this timescale. They are working with NRS to quality assure and respond to our various queries on the data and analysis we have undertaken so far. They are also working the University of Dundee regarding data on drugs to help provide some contextual information to some of the findings or trends on the drug deaths.

Next key actions: Post completion of the report, internal sign off processes will be followed and the report will be published on the SG website.

Recommendation 1.2

Owner: NHS (to lead) and SPS

Progress made: The National Prison Care Network will monitor data from NHS Boards on evidence and implementation of the NHS Deaths in Custody Support Toolkit, the data to be monitored has been agreed. Data collection issues are currently being considered and actioned.

A National Executive Leads Collaborative (NELC) has been established, this is a group of senior leaders from across all NHS Board areas to provide a forum to share practice and drive improvement in prison healthcare. As part of this, a national performance HEAT Map is being developed for use by the NELC. The set up of NELC and the HEAT Map is to avoid recommendations being ‘lost’ in the system through lack of assigned ownership and to support a focus on driving continuous improvement. Deaths in prison custody will feature as part of this HEAT map which is in development. The 2024/25 NHS Board Annual Delivery Plan (ADP) included an ask that the Toolkit is implemented. The ADP is the way that ministerial priorities for health and care feed into what Health Boards are asked to deliver. All Health Boards have committed to implementing the Toolkit. Given this commitment and the monitoring processes in place 1.2, 2.1 and 5.1 have been considered implemented.

Next key actions: Monitoring processes to be kept in place.

This recommendation has now been implemented.

Recommendation 1.3

Owner: SPS

This recommendation has now 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.

Recommendation 2.2

Owner: SPS

This recommendation has been implemented.

Recommendation 2.3

Owner: NHS (to lead) and SPS

This recommendation has now been implemented.

Recommendation 2.4

Owner: SPS

This recommendation has now been implemented.

Recommendation 2.5

Owner: SPS, NHS and Scottish Government

This recommendation has been implemented.

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

Progress made: The data sharing agreement between SPS and COPFS remains at an advanced stage. Separately, COPFS and SPS continue to develop a process for the earlier sharing of information from the DIPLAR report by SPS. The process will allow COPFS to assess the prejudicial risk of any factual information SPS intend to release and the development of necessary internal policy guidance for the COPFS part of this process is well underway. In the meantime, COPFS have confirmed their willingness to consider any proposed DIPLAR for release.

COPFS has developed new draft policy guidance to support the earlier provision of factual information in all Custody Death Unit investigations, including those where there is still potential for criminal investigations. The draft policy has been shared within COPFS as part of an internal consultation exercise, including with staff and senior leaders.

COPFS continues to support SG and HIS in the implementation of framework improvements aimed at improving the quality, consistency and timeliness of information provided by the NHS, specifically Significant Adverse Event Review (SAER). As part of this process, COPFS staff are engaging with HIS and NHS Boards. A programme of improvement action has been agreed for the remainder of financial year 2024/2025.

Next key actions: SPS to see further advice around remit of the data sharing agreement. COPFS updated draft policy guidance regarding the earlier provision of factual information in CDU investigation will again be shared with senior leaders in September for approval and then the Law Officers will be asked to consider and approve the new policy. It is hoped that this can be achieved by October.

Recommendation 3.3

Owner: SPS and NHS

This recommendation has been implemented.

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

Progress made: SPS Post Traumatic Incident and Resilience policy including accompanying guidance has been developed but still subject to stakeholder input with some recommendations for changes to be made. Discussions are ongoing into training options due to the ability to release staff to attend and the required ongoing support. For NHS related update - see update at 1.2 above.

Next key actions: Post Traumatic Incident and Resilience policy is expected to be finalised by the end of September 2024, and the interim process will continue until new arrangements are introduced. User feedback on the interim process has been positive. Lifelines Scotland, Staying Well Road Trip and ‘Lifelines Prison Service’ will be launched to coincide with Hidden Heroes Day at the end of September 2024. Actions are ongoing to identify alternative options for training to accompany policy launch, with multiple options being explored via EAP, Lifelines Scotland and possible in-house interim arrangements.

Recommendation 4.2

Owner: NHS (to lead) and SPS

Progress made: STILT in establishments is ongoing and NES trauma modules continue to be available to staff via the MyLO online training platform. Other work on evaluation of trauma informed practice was due by end of March 2024 and a final phase 1 report scheduled for May 2024, however, due to unforeseen circumstances an update this is delayed. The content of the Prisoner Survey, including trauma related questions should be available for analysis in summer 2024, however, due to unforeseen circumstances this is delayed. For NHS related update - see update at 1.2 above

Next Key Actions: No next steps provided

Key theme: SPS and NHS documentation concerning deaths

Recommendation 5.1

Owner: SPS (to lead) and NHS

This recommendation has been implemented.

Recommendation 5.2

Owner: SPS (to lead) and NHS

This recommendation has been implemented.

Recommendation 5.3

Owner: SPS

Progress made: SPS are considering how to move forward with this recommendation. In the meantime, the current Independent Chair has also started chairing several of the DIPLARs for deaths from apparent natural cause to inform future arrangements and improve understanding.

Recommendation 5.4

Owner: SPS

This recommendation has been implemented.

Progress on Advisory Points

Advisory Point 1

Owner: SPS and NHS

Progress made: Organisations are keen to continue to work with a family reference group and will engage with Families Outside. Neither SPS nor NHS feel this sits within their remit to commission a national bereavement resource. Families Outside indicated at the DiPCAG that they might be best placed to work on this advisory point, discussions will need to take place.

Advisory Point 2

Owner: SPS

Progress made: SPS noted that there are no immediate plans to progress this recommendation as it would require a large estates project and significant budget implication which the SPS is not currently resourced to deliver. SPS will, however, further consider the evidence base and prepare a business case for funding to SG if required.

Next Steps: SPS to take forward the development of a toolkit which will assist in the evaluation of a cell environment. This Toolkit may not result in a change of location for cell alarms.

Advisory Point 3

Owner: SPS (to lead) and NHS

Next Key Actions: A further review of the DIPLAR commenced in February 2024, including a full audit of all concluded DIPLARs since implementation, engagement with operational staff including NHS Prison Healthcare colleagues and focused conversation with the current Independent Chair. There were initially a limited number of fully completed DIPLARs for analysis; further completions have now audited and a revised template is currently out for consultation. This advisory point will be addressed in the revised guidance.

Next steps: Collation of consultation feedback to inform final revised template. Revision of guidance and consultation on revised draft. Revised guidance and template to be implemented. NPrCN are due to review Toolkit in October 2024, this should be considered as part of the review.

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.

Advisory Point 6

Owner: SPS

Progress made: SPS have discussed with the Chaplaincy and Health team and a review of completed DIPLARs has been completed to inform revision of draft.

Next steps: This advisory point will be incorporated in the revised DIPLAR guidance following the current review.