Deaths in Prison Custody Action Group minutes: July 2023

Minutes from the meeting of the group on 11 July 2023


Attendees and apologies

  • Gillian Imery, Independent 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
  • Asha Anderson, representative for families bereaved by a death in prison custody
  • Jan Savage, Executive Director, Scottish Human Rights Commission
  • Luis Felipe Yanes, Legal & Policy Team, Scottish Human Rights Commission
  • Cat Dalrymple, Deputy Director, Community Justice, SG
  • Suzy Calder, Interim Head of Health, SPS
  • Dr Craig Sayers, Clinical Lead, National Prison Care Network, NHS
  • Eilidh Cunningham, Assistant Programme Manager, National Prison Care Network, NHS
  • Nancy Loucks, Chief Executive, Families Outside
  • Bryan Burns, Detective Chief Inspector, Police Scotland
  • Andy Shanks, Head of Scottish Fatalities Investigation Unit, COPFS
  • Nicola McAndrew, Team Leader, Prisoner Healthcare, SG
  • Nicola Gilroy, Senior Policy Officer, Prisoner Healthcare, SG
  • Kim Hunter, Community Justice, SG
  • Laura Begg, Community Justice, SG


  • Debbie Carroll, Heath of HSIU, COPFS
  • Sue Brookes, Director of Strategy and Stakeholder Engagement, SPS
  • Sheena Orr, Chaplaincy Advisor, SPS
  • Stephanie Blair, Principal Procurator Fiscal Depute, COPFS
  • William Stewart, Governor, HMP Shotts, SPS
  • Catherine Haley, Healthcare Improvement Scotland
  • Matt Paden, Detective Superintendent, Police Scotland

Items and actions


Gillian Imery welcomed everyone to the fifth meeting of the DiPCAG. Jan Savage, Executive Director and Luis Felipe Yanes, Legal & Policy team were welcomed to the meeting, on behalf of the Scottish Human Rights Commission (SHRC). Andy Shanks, the new Head of the Scottish Fatalities Unit at Crown Office and Procurator Fiscal Service (COPFS) was welcomed to the meeting. DCI Bryan Burns was thanked for attending the meeting on behalf of DSU Paden. A number of apologies were noted.

Gillian Imery reminded the group of the importance of the work and the need to make improvements and noted the number of deaths in prison custody that had taken place in recent weeks.

Minutes of last meeting and update on actions

No comments were received on these. They have now been published on the DiPCAG page on Scottish Government website.

Two actions from the last minutes:

  • Nicola McAndrew to facilitate Gillian Imery being invited to a prisoner healthcare SLG meeting

Gillian Imery advised that she had met with the Chairs of the healthcare Strategic Leadership Group on 22 June.

  • All to consider whether they were undertaking a piece of work that the family reference group could contribute to and help progress.

Gillian Imery advised that representatives from Scottish Prison Service (SPS) are attending next family reference group meeting to speak about ongoing work in relation to the review of the Critical Incident Response and Support processes and improving accessibility for family members to report concerns about someone in prison.

All of the other organisations were encouraged to bring pieces of work they are progressing to the family reference group for their contributions.

Chair’s Update

Gillian Imery advised the group that she had met with the co-chairs of the healthcare strategic leadership group on 22nd June and provided them with a candid update.

At the request of the Criminal Justice Committee, Gillian Imery advised she had provided a candid update on 19th June and is likely to be invited to appear in front of the Criminal Justice Committee after recess.

Gillian Imery also advised that she was due to meet with the Cabinet Secretaries for Justice and Health on 3rd August to provide them with an update.

There was a discussion about how Gillian Imery was making an assessment as to whether or not a recommendation had been implemented. Gillian Imery advised in doing so she was looking at the spirit of the recommendation and ensuring meaningful changes had been implemented.

Update on implementation of recommendations 

Suzy Calder provided an update on behalf of the SPS of work that had been progressed since the previous meeting in March.

Work was ongoing to update the SPS website and they were looking at how information for families could be made more central on the website.

The new ligature cutters were now in place in every establishment and all staff had been trained on their use. A video had been produced on how to use them which was available on the internal SPS training site.

In respect of the recommendations that relate to the DIPLAR, the revised paperwork and guidance had been tested at a DIPLAR in May and due to be tested at a further DIPLAR that week. Some amendments had been made to the flow but not the content. Hoping to very quickly thereafter have executive management group approval and then full implementation in August. Revised process will then be reviewed after 6 months.

In relation to the understanding and prevention of deaths workstreams, data had been extracted from around 200 DIPLARs. SPS Head of Data and Analysis was going to undertake an analysis of this data in an effort to identify trends about what has worked well and what hasn’t.

Ongoing work to create a more accessible system to report concerns centred around creating a telephone concern hotline. This will be located in an area of the prison where there is 24/7 cover. The answering machine message will be changed so first part of message relates to what to do if have an urgent concern. Briefings and support for staff responding to calls will be in place by the end of August.

Suzy Calder clarified that the telephone hotlines were in addition to the electronic concern forms that can be completed with the assistance of a number of professionals such as social work department and Families Outside. A ‘Raising Concern’s booklet was being created and would be made available when the telephone hotlines went live.

In relation to the recommendations that relate to trauma informed practices, four trauma modules by NHS Education for Scotland (NES) will be made available shortly to staff on the staff system. Majority of Governors have attended trauma training and now looking at resources to train all senior managers.

The group were advised that William Stewart, the Governor in Charge representative was retiring shortly and a new representative would be appointed.

Suzy Calder indicated that the SPS would welcome a wider discussion on advisory point 1 and the establishment of a bereavement forum. SPS have a number of ongoing pieces of work led by the Chaplaincy team developing initiatives around loss.

Dr Craig Sayers provided an update on behalf of the National Prison Care Network (NPrCN).

The toolkit outlining rules and responsibilities following a death is an advanced draft that will be circulated to NHS Boards on 21st July for feedback. Toolkit includes a number of components such as: process to follow in and out of hours; confirmation of death processes; SAER/Fatal Accident Inquiry (FAI) processes and family engagement.

Confirmation of death training is now online and accessible. Ambition is to have all nurses trained within 6 months.

A document was being produced around FAIs and will be circulated to Forth Valley for feedback. In person FAI training has been arranged for September.

In relation to preventative work, the NPrCN are progressing some longer term pieces of work, such as target operating models with a focus on workforces. A priority piece of work is the review of Management of Offenders at Risk (MORs) in respect of substance misuse. Working with the Royal Colleague of Emergency Medicine on this. Currently out for consultation and aiming to share draft with SPS end of August/September.

In respect of trauma informed care a framework has been approved by their oversight board. This will need discussion at board level as more in depth than death in custody work.

Asha Anderson commented that the family reference group were keen to have the National Prison Care Network attend to discuss their work as there was lots that families could input into this work.

Andy Shanks provided an update on behalf of COPFS. The Scottish Fatalities Unit (SFIU) have an improvement group, aims are: increasing public confidence; improving standard of service and increasing the engagement of families with the process and reducing journey time.

COPFS are improving guidance on their external website. Considering ways to enhance public health messaging in respect of themes arising from FAIs, not something they have previously done. Working on a terms of reference for a lived experience panel. The custody deaths unit is full established.

In relation to recommendation 3.2 and information sharing agreement between COPFS and SPS, real steps forward to progress this are being made. Confident this will help the flow of information in the future.

DCI Bryan Burns provided an update on behalf of Police Scotland. Police Scotland are taking the lead on a deaths in custody governance group and information sharing agreement. Work on that has stalled a little and they are linking in with COPFS. Legally a number of issues to be resolved to ensure that information is appropriately shared.

Have started raising awareness throughout Police Scotland of the new investigative process that is going to be piloted under the key recommendation.

Update on implementation of the key recommendation

Cat Dalrymple provided an update on behalf of the Scottish Government. Disappointed that couldn’t get pilot up and running in April as had hoped at start of year. Made some amendments to the nature of the pilot, to include an initial phase more akin to a desktop exercise. This is to address concerns about the pilot being an untested process and potentially causing harm to families. There are challenges around information sharing. Now working towards a date in September.

COPFS are to identify cases that have been through the FAI process and all of the information will have already been shared other than with HM Inspectorate of Prisons for Scotland (HMIPS). There is a draft guidance document in place and working on a draft evaluation guidance document.

Cat Dalrymple advised the group that the Scottish Government have done all they can do to get the pilot up and running and are now reliant on all of the partners to ensure they are in a position to ensure the pilot can operate and need all partners to engage. Commented that she was very grateful for support and creative solutions.

Gillian Imery commented that she understood that there were difficulties in creating a product to meet this recommendation because of complications created by the constitutional position of the Lord Advocate and the need to operate within those parameters.

Nancy Loucks advised that Families Outside and HMIPS were talking to other jurisdictions to understand better their processes and what works and what doesn’t work.

Jan Savage advised that SHRC had been approached by HMIPS to be involved in the pilot and had allocated a member of staff who had been heavily involved in the initial review. SHRC were committed to supporting the trial of the new process.

Update on working group to progress recommendations focusing on understanding and preventing deaths in prisons

Gillian Imery provided an update on this workstream.

Head of Justice Analytical Service (JAS) has agreed to provide leadership to the work required to undertake a thorough analysis of deaths and to enhance an initial analysis undertaken by SPS Head of Data and Analysis. SPS are providing data and will provide quality assurance and context to support JAS.

This will be the first report in a series of publications. Further in depth analysis of causes of deaths to be undertaken in collaboration with National Records Scotland and SPS have undertaken a review of DIPLARs to identify learning points.

Update from family reference group

Asha Anderson thanked everyone for their updates. Families still felt that progress was a bit slow and it was reassuring to hear about ongoing work. Asha Anderson advised that everyone was welcome to come to a family reference group meeting to discuss their ongoing work. This wasn’t just for the benefit of families, it could also be helpful to those doing work to gain the perspective of families.

Stewart Taylor reminded the organisations that families want to see real action and organisations taking responsibility for making improvements.

Nancy Loucks advised that Families Outside were being approached by more families looking for support and copies of the family support booklet.

Any other business

Jan Savage advised that she found it illuminating listening to the updates from the organisations. The SHRC had been looking at their priorities going forward and considering if they should have a greater role in scrutinising deaths investigation and an ongoing monitoring role. SHRC are independent and part of their role is considering whether human rights are being upheld.

Nancy Loucks commented that Families Outside were universally seeing more proactive engagement by the SPS with families.

Gillian Imery advised the group that the date of the next meeting was likely to be in October.

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