Death in prison custody: action plan - updated January 2026

Death in Prison Custody – Action Plan – Update January 2026

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) January 2026 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: A proposed model was developed and piloted twice, but the pilots showed it could not deliver genuine independence, timely investigations, or effective family engagement. COPFS’ constitutional role meant the process could never be fully independent and investigations would be delayed until criminality was ruled out. The model risked duplicating the Fatal Accident Inquiry (FAI) process and confusing families. As a result, the Cabinet Secretary for Justice and Home Affairs wrote to the Criminal Justice Committee on 30 May 2025 to outline the key developments and limitations of implementing the key recommendation. The letter concluded that:

“In summary, the Scottish Government accepted in principle the key recommendation of the Independent Review. An approach to implement that recommendation was decided upon by the working group and piloted. The pilot exercises were required to understand how that approach would work in practice. They demonstrated crucial shortcomings of that particular model and highlighted the primacy of the FAI process. The Scottish Government is now progressing a review of the FAI process, the creation of a National Oversight Mechanism and additional family support services. These measures, as part of the wider package of measures the Cabinet Secretary announced on 23 January 2025, will she believed will deliver on the objectives underpinning the key recommendation. On that basis, the Scottish Government will not continue to progress the key recommendation”.

Next key actions: Further recommendations were made and accepted by the Scottish Government in January 2025 after the FAI determination into the deaths of Katie Allan and William Lindsay. As a result of these recommendations, an independent review in to the FAI system was undertaken by Sheriff Principle Abercrombie with findings published in January 2026. The Scottish Government also committed to the development of a new National Oversight Mechanism to improve transparency, accountability, and learning and to introduce a new family advocacy support role for bereaved families. Whilst the decision was taken to not progress the Independent Review’s key recommendation, work in this area continues and these measures aim to deliver the underlying objectives to this recommendation more effectively.

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: SG Justice Analytical Services (JAS) published their report in March 2025 which included comparisons with trends in general population. This work provides an agreed dataset and increased transparency. This analytical work only goes some of the way to achieving this recommendation and concern has been expressed regarding the focus on post-death processes rather than prevention.

Next key actions: The Scottish Government’s development and implementation of a National Oversight Mechanism (NOM) will involve further stakeholder engagement to ensure that prevention is embedded. The reporting from JAS will also contribute to the development of the NOM.

Recommendation 1.2

Owner: NHS (to lead) and SPS

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: While there has been measurable progress in governance, clarity, and inter‑agency coordination, families’ experiences indicate that Recommendation 3.2 has only been partially implemented. Meaningful improvement will require sustained cross‑agency effort, clearer communication with families, and cultural change, rather than procedural adjustments alone.

Next key actions: On-going focus on engagement with families to ensure continued progress on this recommendation. This will also be crucial in the development of both the NOM and the Family Advocacy service.

Recommendation 3.3

Owner: SPS and NHS

The 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: NHS Scotland has embedded structured wellbeing checks within prison healthcare teams, with 100% compliance reported for regular one‑to‑one meetings with line managers, including following deaths in custody. Staff wellbeing support is now clearly set out within the NHS Support Toolkit, strengthening consistency and visibility of care for healthcare staff. SPS has made substantial progress on staff wellbeing through the launch of a Senior Leader Wellbeing Support Programme in November 2025, informed by UK prison leadership research and delivered in partnership with NHS Lothian’s Rivers Centre. Early uptake has been positive, with one‑to‑one support already underway and group sessions scheduled for early 2026. In parallel, significant progress has been achieved on the Post Trauma and Resilience Policy, which has been agreed with trade unions and professional associations and is on track for launch in February/March 2026. This includes a new digital reporting system, automated management notifications, follow‑up processes, a self‑assessment tool, and expanded access to trauma, resilience and wellbeing resources for staff and their families.

Next key actions: Key next steps focus on implementation, embedding and sustainability. A dedicated SharePoint landing page will be launched to host guidance, training and resources, supported by wider staff engagement activity, including advocacy through staff stories, podcasts and drop‑in sessions to encourage uptake and cultural change.

Recommendation 4.2

Owner: NHS (to lead) and SPS

Progress made: Over the past two years, SPS and NHS have made joint progress in embedding trauma‑informed support for people held in prison following a death in custody. A key development has been the national rollout of trauma‑informed practice training through the Trauma‑Informed Toolkit, delivered collaboratively across SPS and NHS services. The toolkit has recently undergone a comprehensive review to assess its effectiveness and ensure alignment with current best practice, with agreement in place to continue evaluation and learning from its implementation. Access to trauma‑informed training is now available to staff across all establishments, and expectations around completion have been embedded within local Personal Development Plans (PDPs). This has helped reinforce trauma‑informed practice as a core professional requirement rather than an optional add‑on. SPS confirmed that staff continue to have access to the toolkit, supporting greater consistency in how trauma‑informed approaches are understood and applied across custodial settings

Next Key Actions: This recommendation has been implemented

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 has fully implemented this recommendation through the recruitment of four independent DIPLAR chairs, each bringing a range of relevant professional experience across prison, health and social care settings. These independent chairs have been in post since September/October 2025 and are now actively chairing all DIPLAR meetings, strengthening independence and consistency in the consideration of deaths in custody. Robust governance arrangements have also been established, including the use of trackers and an assurance group to provide objective oversight and assurance that learning points are identified and followed up.

Next Key Actions: This recommendation has been implemented.

Recommendation 5.4

Owner: SPS

This recommendation has been implemented.

Progress on Advisory Points

Advisory Point 1

Owner: SPS and NHS

Progress made: Discussion of Advisory 1 has clarified that while there is broad support for the principle of a bereavement platform for families, there is currently no agreed owner. Both NHS and SPS have indicated that delivering a family‑focused bereavement forum is not squarely within their remit, although SPS has highlighted existing bereavement‑related activity that could align with or complement family support if scaled. The group has reinforced that the advisory is about commissioning an independent platform rather than direct delivery, with third‑sector providers identified as potential options. There is also recognition that “forum” has not been clearly defined and that bereavement support may need to be offered through a range of formats, including in‑person, online, or hybrid models, taking account of risks and accessibility.

Next Key Actions: The group will need to agree a clearer definition of the intended bereavement platform, including its purpose, scope, and preferred delivery models. Further work will explore what commissioning would mean in practice, including whether the platform could be incorporated within the Family Advocacy (FA) service specification. If incorporation within FA is not feasible, this will be brought back to the group for further discussion and direction.

Advisory Point 2

Owner: SPS

Progress made: SPS has progressed a review of the scope for placing emergency alarms within reach of the cell bed and has identified that installing a bedside alarm alone would not adequately address the issue. As a result, a broader review is underway, considering digital solutions, the wider cell environment, and the need for robust, joined‑up operational processes. This work is being taken forward through a short‑life working group with representation from five NHS Boards and the Scottish Ambulance Service, and is progressing well, with completion targeted for Q2 2026. Consideration is also being given to enhanced support planning for individuals at higher risk of health incidents, with the expectation that these plans will remain under regular review.

Next Key Actions: SPS will continue to progress the work of the short‑life working group, including the evaluation of emerging technologies and digital monitoring tools, ensuring any solutions are carefully assessed and proportionate to the underlying risks. Clarification will be required on the intended scope and applicability of any new technology, including whether pilots or future roll‑out would apply to all cells or specific contexts. SPS will keep this work under review and provide updates as findings emerge, recognising that the advisory identifies an issue that may require a broader system‑level response rather than a single technical solution.

Advisory Point 3

Owner: SPS (to lead) and NHS

Next Key Actions: The DIPLAR process now includes the capturing of relevant relationships and insights from others in custody, and SPS are committed to ensuring this element is consistently considered in practice. The SAER is a standard NHS‑wide process, applied uniformly across all settings including prisons, and therefore cannot be modified specifically for the prison context, though relevant information can still inform reviews within the existing framework.

Next steps: This advisory point has been implemented.

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: Progress has been made in this area, with increased clarity on the importance of consistent and sensitive approaches to memorial services, letters of condolence and donations from people held in prison. There is a shared understanding of the need for clear communication with families about memorial arrangements, and SPS has highlighted that families’ wishes are routinely taken into account. Experience to date demonstrates that complex circumstances, including the need for multiple or separate memorials for different family groups, have been handled sensitively in practice. Maintaining a respectful and consistent approach to memorials and related practices has been recognised as central to supporting families. The development and implementation of these protocols will remain under review to ensure they reflect good practice and respond appropriately to family needs in a range of circumstances.

Next Key Actions: This advisory point has been implemented.