Deaths in Prison Custody Action Group: June 2022

Minutes from the meeting of the group on 21 June 2022.

Attendees and apologies

  • Gillian Imery (Chair), External Chair, Oversight of Recommendations of Review into Response to Deaths in Prison Custody
  • Stewart Taylor, representative for families bereaved by a death in prison custody
  • Cat Dalrymple, Deputy Director, Community Justice, SG
  • Katrina Parkes, Head of Scottish Fatalities Investigations Unit, COPFS
  • Stephanie Blair, Principal Procurator Fiscal Depute, COPFS
  • Matt Paden, Detective Superintendent, Police Scotland
  • Chris Mill, Detective Chief Inspector, Police Scotland
  • Nicola McAndrew, Team Leader, Prison Healthcare, SG
  • Suzy Calder, Interim Head of Health, SPS
  • Sue Brookes, Director of Strategy and Stakeholder Engagement, SPS
  • Sheena Orr, Prison Chaplain, SPS
  • Catherine Haley, Senior Inspector, Healthcare Improvement Scotland
  • Dr Craig Sayers, Clinical Lead, National Prison Care Network, NHS
  • Professor Nancy Loucks, Chief Executive, Families Outside
  • Laura Begg, Policy Manager, Community Justice, SG


  • Laura Waddell, Police Scotland
  • Rachel Wallace, Prison Healthcare, SG

Items and actions

Welcome and introductions

Gillian Imery welcomed everyone to the group and in particular thanked Stewart Taylor for attending on behalf of bereaved families. The Chair explained that the purpose of the group is to have oversight of the progress of implementation of all of the recommendations of the independent review. It was acknowledged that some members were also members of the working group on the key recommendations and thanked agencies for providing an update on their work in advance of the meeting.

Gilliam Imery thanked families for the contribution that they had made to the Independent Review and emphasised that this group demonstrated a positive desire to make changes and improvements to provide a different experience for families. 

Terms of reference

Gillian Imery invited contributions for inclusions within the Terms of Reference for the group. The Chair also invited suggestions of any agencies that should also be represented on the group. Emphasised that it should be reflected within the Terms of Reference that there should be a focus on delivering what is behind the recommendations. Terms of reference should also reflect matters outside the scope of the group such as the existing role of the Police and Lord Advocate.

Update on work done to date to implement recommendations

Sue Brooks and Suzy Calder provided an update on behalf of the Scottish Prison Service (SPS). It was highlighted that the SPS welcomes the conclusions of the Independent Review and they recognise the need to work with the NHS to implement many of the recommendations. Caution was expressed about the need to avoid duplication of effort.

It was explained that some practical progress had been made. The recommendations had been discussed with Governors and they had provided their full support. An internal group has been set up to look at response to deaths. The SPS has secured a National Suicide Prevention Post which started in May. All of the prison estate have ordered privacy screens and a working group has been set up to examine the introduction of ligature cutters. Two additional NHS staff have joined as secondees and were attending all DIPLARs. Have met with the National Prison Care Network to discuss recommendations and agree on which organisation will lead.

Nancy Loucks raised a concern about how widely available a family support booklet that had been developed between the SPS and Families Outside was to bereaved families. Sheena Orr undertook to look into whether it could be published on the SPS website.

Stewart Taylor highlighted that it was important to keep sight of the fact that every person who dies whilst in prison has loved ones and expressed the view that someone from the prison should visit family members.

Sue Brooks acknowledged that there were gaps in communications with families and there was a need for training on how to communicate effective with families as some governors felt they lacked the necessary skills.

Nicola McAndrew provided an update on behalf of the Prison Healthcare Team, Scottish Government. It was explained that they have responsibility for sponsorship on the National Prison Care Network and funding had recently provided for an extra resource to work on progression of the recommendations.

Craig Sayers provided an update on behalf of the National Prison Care Network. It was explained their next step is to identify the best individual within the NHS to lead on individual recommendations and to check with health boards whether any good local work ongoing that can be rolled out nationally.

Catherine Haley provided an update on behalf of Healthcare Improvement Scotland (HIS). It was explained that HIS haven’t been commissioned to take forward any work resulting from the review and it didn’t feature in their work plan for 2022 to 2023. They are willing to participate in a working group to consider recommendation 1.1.

Gillian Imery reminded the group of the need to be mindful that even agencies that were not named in a particular recommendation might still have an overall interest in the implementation of the recommendations.

Stephanie Blair provided an update on behalf of Crown Office and Procurator Fiscal Service (COPFS). The group were reminded at the outset of the constitutional role of the Lord Advocate in the investigation of deaths. The key recommendation complements the COPFS investigation and their statutory obligations in respect of contact with families.

In relation to recommendation 3.2, COPFS are working with SPS to develop a memorandum of understanding about disclosure of information to families.

Matt Paden provided an update on behalf of Police Scotland. It was explained whilst they were not a specific owner of any of the recommendations, they had a keen interest and want to help progress. A Deaths in Custody pilot was being undertaken alongside COPFS, which was a national pilot involving drugs deaths and suicides within prisons with the aim of ensuring a consistent approach nationally. Emphasised that Police Scotland are committed to improving engagement with bereaved families.

Gillian Imery reassured the group that the new investigation process was an enhancement to existing processes rather than a replacement and that work to improve existing processes shouldn’t be delayed. Clarified that the Review’s advisory points will be treated in the same way as the recommendations. Chair also informed the group of her intention to generate from the group an action plan for delivery of the recommendations.

Update from Scottish Government working group on key recommendation

Cat Dalrymple provided an update on behalf of the working group on the key recommendation. The new investigative process won’t replace existing processes.

Working group in respect of the key recommendation has met twice and had constructive discussions. Held a roundtable discussion with other jurisdictions to try to learn lessons. Key finding from that was that investigative processes in other jurisdictions do not necessarily concluded any quicker and often take twelve to eighteen months, although this is clearly dependent upon individual circumstances. It was considered that the investigation would be wider than current process and needs to meet family expectations and needs. Requires caution to ensure new process is not duplication of existing process but still meeting Review recommendations. It was highlighted that setting up a new independent investigative process would not be a quick process, particularly if a new body was to be created as that would require legislation Also need to remember constitutional position of others involved in the working group. First stage of working group is to consider what new investigative process will look like and second stage is to consider who will undertake that role.

Engagement with families

Stewart Taylor expressed view that families need to be closely involved and acknowledged that was a challenge for the Chair and agencies involved in implementation. It was also commented that the structure of the NHS presented challenges in ensuring consistency.

The group were reminded that the family advisory group that was created during the Independent Review no longer existed.

Gillian Imery explained to the group that she was setting up a family reference group which she envisaged would help shape progress of the recommendations by being a group that working groups or agencies could go to and ask their opinions on ideas and options and provide assistance. Also that a member of the family reference group would provide representation on the DiPCAG. The family members would be asked to decide amongst themselves who that representative would be.

Stewart Taylor agreed that he felt this was a good way for the views of families to be represented.

Nancy Loucks provided some further information about the family reference group as she was providing assistance in helping set it up. She advised the group that ten people from seven families had expressed an interest in being part of the group. Some of those people had been part of the Independent Review, whilst others hadn’t. Nancy Loucks expressed strong view that there should just be one group involving families set up, that each working group can make use of. Also that she felt it was important families were represented on the DiPCAG.

Transparency on progress

Gilliam Imery invited views on how the group could make the wider public and families who didn’t want to be involved in the family reference group aware of progress on the recommendations.

Gillian Imery advised the group that she had given a commitment to the Cabinet Secretary to provide a progress report in November 2022, which was a year after publication of the Review. She emphasised that the purpose of that report would be to demonstrate the efforts made to implement the recommendations and also where improvements were still to be made. Suggested any action plan arrived at by the group could potentially be published and advised that there had also been suggestions an online tracker should be created. The group were also advised that the Cabinet Secretary was making a statement in Parliament the following day to provide an update on progress.

Cat Dalrymple suggested that it may be possible to create a communal space for minutes of meetings to be shared which would increase transparency.

Next steps 

Gillian Imery reminded the group that the governance structure was that the DiPCAG was the oversight group that any other working groups would report to. Invited views from the group on any other working groups that should be set up in addition to the working group on the key recommendation that was already progressing that recommendation. Gillian Imery suggested that a working group on recommendation 1.1 was required to concentrate effort on progressing that recommendation and another possible working group to focus on communication with families. Acknowledged that too many working groups could cause confusion and agencies may already have set up their own working groups that would cross over with the work of a working group.


  • Gillian Imery/Laura Begg to discuss with Cat Dalrymple options for increased transparency on progress
  • all to email Laura Begg on suggestions for another other working groups that should be set up to progress work
  • Laura Begg to circulate Terms of Reference for the group and all to provide any comments
  • Laura Begg to circulate action plan of work. All to engage with providing further information about their planned work to provide further detail to the action plan
  • Sheena Orr to investigate whether Family Support Booklet can be made available on the SPS website
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