Deaths in Prison Custody Action Group minutes: August 2024

Attendees and apologies

• Alex Doig, Scottish Government (Chair)
• Andy Shanks, Crown Office and Procurator Fiscal Service 
• Debbie Carroll, Crown Office and Procurator Fiscal Service 
• Kerry Knox, Families Outside  
• Cath Haley, Healthcare Improvement Scotland  
• Craig Sayers, National Prison Care Network
• Eilidh Cunningham, National Prison Care Network
• Bob Campbell, Police Scotland  
• Sarah Angus, Scottish Prison Service  
• Sheena Orr, Scottish Prison Service
• Suzy Calder, Scottish Prison Service
• Siobhan Taylor, Scottish Prison Service
• Laura Begg, Scottish Government
• Kim Hunter, Scottish Government
• Karen MacNee, Scottish Government
• Sarah MacQueen, Scottish Government

• Rose Munenura, Scottish Government

Apologies  

• Stephanie Blair, Crown Office and Procurator Fiscal Service  
• Nancy Loucks, Families Outside
• Asha Anderson, Family Reference Group
• Stewart Taylor, Family Reference Group
• Cat Dalrymple, Scottish Government
• Emma Dilger, Scottish Government
• Nicola McAndrew, Scottish Government

Items and actions

Welcome and introductions

The meeting was opened, and attendees were thanked for attending the DiPCAG and for providing updates in advance of the DiPCAG meeting. Apologies were noted. 

Chair’s update

The Key Recommendation Roundtable event occurred on 8 August, which Alex Doig chaired. Alex reflected that during this event, agreement was reached that the new investigative process that had been developed by this group did not meet the requirements of the key recommendation. Alex explained that the focus now was to consider alternatives that would achieve the underpinning objectives of the key recommendation.

Alex updated that since the last DiPCAG meeting, the Family Reference Group had met and that Nancy Loucks was now chairing these meetings. A representative from Healthcare Improvement Scotland (HIS) attended to discuss the review being undertaken of the Significant Adverse Event Review (SAER).

The group were advised that the updates provided at this meeting will be used to update the Cabinet Secretary on progress against the remaining recommendations, and that any intended timescales or challenges and blockers should be discussed.  

Updates on the Recommendations

Key Recommendation

Alex gave thanks to everyone for their involvement in the pilots and acknowledged that the pilot process had now concluded. The roundtable event occurred on 08 August 2024, which was a key milestone, and officials are now working on outputs and next steps following this event.

Justice Analytical Services update

Justice Analytical Service (JAS) provided an update on 1.1 and 3.4 explaining that they are working with colleagues in National Records Scotland (NRS) to develop a new report. This report will use more detailed information, obtained from NRS and will contain more comparisons with the general population when exploring causes of death. NRS are publishing Age-standardised Death Rates Calculated Using the European Standard Population data from 2023-24 in September 2024 which will also be incorporated into the report.

JAS previously committed to an annual publication on deaths in custody, the remit of this annual report is being scoped out. To do that, following publication of their next report JAS will review the outputs and conduct a user engagement assessment to help inform what the annual report might include.

It was queried whether the next report will disaggregate data such as demographics and JAS clarified that the report would make use of high-level data and the relevant ‘death’ categories currently used by NRS.

 As part of the discussions around who may be the most appropriate organisation to deliver an oversight mechanism function, it was highlighted whether the annual analysis should sit within JAS or be externally procured. It was, however, recognised that there would be substantial costs associated with this. 

NHS update on implementation of Recommendations

Recommendations 1.2, 2.1, 4.1, 4.2, 5.1 and Advisory Points 1 and 3

Eilidh Cunningham provided an update on behalf of the National Prison Care Network, explaining that the NHS responded to recommendations directed at them by developing the NHS Deaths in Prison Custody Toolkit. Eilidh explained that the Network are currently having issues sharing their data dashboard with the NHS Boards to monitor the implementation of the recommendations. This has resulted in the Core Steering Group agreeing to pause the data collection and try to seek a national resolution. Local solutions are also still being investigated in the interim. The Core Steering Group are due to meet week commencing 26 August and will discuss the measures to resolve these issues. The NHS Toolkit is currently in place, and a review is scheduled to commence in October.

Karen MacNee provided an update for SG Healthcare in Custody, including that Health Boards have put additional focus on prisons. The annual delivery plan (ADP) is an ask to all Health Boards which requests Boards to prioritise specific priority areas, the 24-25 ADP for Health Boards includes a specific ask on deaths in custody.  There will be ongoing monitoring and a suite of measures are being developed to demonstrate improvement in health and social care which will include asks in respect of deaths in custody. At the time of this meeting, with the exception of one Health Board, all had confirmed to SG their commitment to implementation of the NHS’ Toolkit or that it had already been implemented.  

Post-meeting note: Confirmation from the final Health Board has been provided to confirm that the Health Board is committed to implementation of the Toolkit. Given this commitment from the Health Boards and the mechanisms in place to review implementation it has been agreed that Recommendations 1.2, 2.1 and 5.1 are now considered implemented.

Cath Haley further outlined that the HIS inspections of the prisons will also monitor against the NHS Toolkit. The Health Boards will also have to complete a self-evaluation and submit this to HIS. In addition, they will need to confirm that certain training has been undertaken.  

Crown Office and Procurator Fiscal Service updates

Andy Shanks provided an update on behalf of COPFS on recommendation 3.2. COPFS have made progress on their internal policy guidance to support the earlier provision of factual information to bereaved relatives. This guidance is currently being consulted on internally with relevant staff. COPFS are aiming for October for wider implementation.

Andy outlined that COPFS are happy to support the earlier sharing of information from SPS Death in Prison Learning, Audit and Review (DIPLAR). SPS highlighted that one DIPLAR report had been shared with a family who requested it. It was, however, heavily redacted which seemed a very unsatisfactory outcome. SPS indicated that they would be looking to meet with the Family Reference Group to discuss.

COPFS are working closely with HIS and SG to support improvement in respect of SAERs, including quality of reporting, timeliness and communication with families.

The data sharing agreement between COPFS and SPS is in the final stages and currently with SPS for final checking. COPFS feel this would not wholly meet the recommendation 3.2; however, it is envisaged that it would provide wider benefits and improve timeliness of information sharing. 

SPS update on implementation of Recommendations

Recommendations 4.1, 4.2, 5.3, and Advisory Points 1, 2, 3, 6

Suzy Calder updated the group on progress on behalf of the SPS recommendations. In relation to 4.1, it was outlined that there had been a volume of work undertaken by the SPS’ HR Department to move away from the previous Critical Incident Response and Support (CIRS) Policy to the new Post Traumatic Incident and Resilience Policy. Suzy explained that it is intended this policy will be launched at the same time as the Lifelines Website at the end of September. Following this, considerations around training for staff will be required.

In February 2024, SPS commenced an evaluation of the revised DIPLAR paperwork and guidance introduced in August 2023. Following on from the evaluation, the DIPLAR paperwork has been revised again to respond to feedback. This has included feedback around improving the flow and making the DIPLAR easier to audit. Feedback was also received from Families Outside.  The new revised DIPLAR guidance will also respond to advisory points 3 and 6.

SPS are still considering how to implement recommendation 5.3 which requires an independent chair for all DIPLARs. A member of the SPS Advisory Board chairs the non-natural cause death DIPLAR meetings. SPS have now trialled that board member chairing DIPLARs for apparent natural cause deaths DIPLAR. Future action requires the creation of a business plan to be able to implement this recommendation. No timescale has been provided at this time as SPS are still considering options. 

SPS questioned the appropriateness of advisory point 2. The intention was understood but it was questioned whether this would achieve its intended aim. It was agreed that this would be discussed further outside of this meeting and may require involvement of SPS estates colleagues.  

Advisory Point 1

SPS and NHS reiterated that do not believe that advisory point 1 around creation of a bereavement forum sits within their remit. Organisations felt there was a lack of clarity in the advisory point and what it was meant to achieve.

Kerry updated the group that Families Outside are doing some work on this advisory point with families and the Family Reference Group. They feel they may be best placed to take this advisory point forward. They are going to consider creating a bereavement group and upskilling their staff to take on this role.

Other members noted concerns about online bereavement forums with regards to trolling and how this could have a massive negative impact on families. 

Police Scotland update

Bob Campell provided an update on behalf of Police Scotland. He advised that there is a working group with representation from each territorial division. The aim of this group is to discuss any challenges with prison deaths and identify more efficient and effective ways when dealing with such deaths. This is to ensure that the next of kin is central and informed to any investigation. Stephanie Blair will chair this group moving forward. 

Family Reference Group

Kerry Knox advised that SPS are looking to attend the next meeting to discuss the provision of DIPLAR reports and the group will also look to discuss the bereavement forum in more detail. 

AOB and close of meeting

No AOB was raised.

It was agreed that any follow up meetings would be arranged in advance of an update going to the Cabinet Secretary. Alex Doig advised that the lifespan of the format of these meetings should be consider, but it was likely another DiPCAG meeting would be arranged for later in the year.