Deaths in Prison Custody Action Group minutes: December 2022

Minutes from the meeting of the group on 12 December 2022.

Attendees and apologies

  • Gillian Imery, Independent Chair, Oversight of Recommendations of Review into Response to Deaths in Prison Custody
  • Cat Dalrymple, Deputy Director, Community Justice, SG
  • Suzy Calder, Interim Head of Health, SPS
  • Sue Brookes, Director of Strategy and Stakeholder Engagement, SPS
  • Catherine Haley, Healthcare Improvement Scotland
  • Dr Craig Sayers, Clinical Lead, National Prison Care Network, NHS
  • Eilidh Cunningham, Assistant Programme Manager, National Prison Care Network, NHS
  • Matt Paden, Detective Superintendent, Police Scotland
  • Nancy Loucks, Chief Executive, Families Outside
  • Katrina Parkes, Head of Scottish Fatalities Investigations Unit, COPFS
  • Stephanie Blair, Principal Procurator Fiscal Depute, COPFS
  • Debbie Carroll, Heath of HSIU, COPFS
  • Nicola Gilroy, Senior Policy Officer, Prisoner Healthcare, SG
  • Laura Begg, Community Justice, SG


  • Sheena Orr, Chaplaincy Advisor, SPS
  • Asha Anderson, representative for families bereaved by a death in prison custody
  • Stewart Taylor, representative for families bereaved by a death in prison custody
  • Nicola McAndrew, Team Leader, Prisoner Healthcare, SG

Items and actions


Gillian Imery welcomed everyone to the third meeting of the DiPCAG. Debbie Carroll and Nicola Gilroy were welcomed to the group as new representatives on behalf of COPFS and Scottish Government Prisoner Healthcare Team respectively.

Minutes of last meeting and update on actions

No comments were received on the minutes of the last meeting.

Previously discussed ways of increasing transparency of the work of the group. A Deaths in Custody Action Group page on the Scottish Government’s website has been created and minutes and documents will be published there. 

Just one action for the last minutes:

All to consider the high level work plan and provide any comments

No comments were received and the high level work plan has been included as circulated within Gillian Imery’s progress report.

Progress report

Gillian Imery reminded the group that she had given a commitment to the Cabinet Secretary back in June that she would publish an update on progress around the year anniversary of the publication of the Independent Review, which was published on the 30 November 2021. All of the agencies involved in progressing the recommendations were provided with a draft of the report for comments on accuracy on the 4 November. Gillian Imery thanked everyone for their responses which were considered and some amendments made to the report. The finalised report was sent to the publishers on 30 November. Due to be published on SG website on morning of 14 December and all agencies will be sent an embargoed copy of the report the day before.

Gillian Imery commented that it had been left open ended in the progress report, whether there would be any further reporting on progress. Would consider the appetite for her to do so in six months/one year and will depend on how long role as Chair lasts.

Forward look to next steps on implementation of recommendations

Sue Brookes and Suzy Calder provided details of the priorities over the next two to three months on behalf of the SPS.

The SPS internal delivery group had met recently with a focus on what they were capable of delivering. A priority will be the DIPLAR review, as it covers a number of recommendations. Aiming to have a paper ready by end of January 2023 to be considered by senior management team. Keen to engage with families, which may lead to slight delay.

Another focus is on the recommendations relating to staff support. Work already in train with HR colleagues looking at the CIRS system. Paper due to go to Executive Management Team. Looking at a broader focus with more support from HR. SPS have a Trauma Informed Delivery Group who have been working with NES to roll out Scottish Trauma Informed Leaders Training. All senior leaders should gain a consistent understanding of trauma informed practices. It has been assessed that other SPS staff working more closely with prisoners may need some bespoke training as their needs seem to fall between two of the levels offered by NES.

A GMA was issued to Governors in Charge that they should be the first point of contact with families following a death. Chaplaincy team have set up sessions on compassionate communication and support for Governors/Deputy Governors.

GMA was also issued to ensure robust processes in place to ensure NOK details and consent to contact NOK were up to date. Have received assurance from across the estate these are in place. Ongoing want to make sure these processes remain in place and are robust.

Nancy Loucks raised a concern that families don’t know how to communicate with SPS and methods of communication could be made clearer.

An assurance was provided that the work around electronic concern forms was still due to be completed by March 2023. 

Craig Sayers and Eilidh Cunningham provided details of the National Prison Care Network’s (NPrCN) priorities for the next 2/3 months.

In relation to the confirmation of death process, NPrCN are working with NES to create a bespoke recorded video. Video due to be recorded 7th February and ready for use in March. Should become mandatory training for primary care nurses. A national Standard Operating Procedure to be drafted to accompany this training. NPrCN to monitor uptake of training.

For recommendations 1.1 and 1.2 a mapping of responses to deaths has been carried out and needs to be added to Visio and shared with SPS.

In respect of recommendations 4.1 and 4.2 mapping of roles has been undertaken and ready to be considered by the workforce group. Need to consider how to embed training requirements.

NPrCN have also been looking at deaths data and trying to assist with analysis of that.

Katrina Parkes and Stephanie Blair provided an update on behalf of COPFS.

A point was made that the recommendations were not for COPFS as they were not named as the owners of any of them. An update can be provided on what COPFS are doing. Part of the key recommendation working group, feel that is working well and delighted with discussions.

On recommendation 3.2 they have joint responsibility for with SPS. COPFS are keen to reach agreement. Two organisations have been communicating over the last few months.

Nancy Loucks asked whether there had been any progress on previous suggestions that FAIs should be held in less formal setting?

Katrina Parkes advised that COPFS have no control over where FAIs take place. It is for the Scottish Courts and Tribunal Service to arrange where a FAI will be held. Any change from a court room being the standard would need to be legislated by Scottish Government.

Sue Brookes commented that whilst she knew that examining the FAI system was not included within the scope of the Independent Review, comments about it are raised persistently and how the adversarial format doesn’t help learning.

Katrina Parkes commented that when the Independent Review first came to be, it was made clear that the purpose was not to look at the FAI system. It was understood that there were no plans to revisit the 2016 legislation. Acknowledged that improvements can be made and COPFS and SG can collaborate on these.

Matt Paden provided an update on behalf of Police Scotland.

The training implications of changes to processes were being considered. Consideration was being given to the role of a family liaison officer and best approach to family support.

Cath Haley provided an update on behalf of Healthcare Improvement Scotland (HIS).

The priorities of HIS lie on the quality assurance side. Looking at if training mandatory and implementation of it.

Considering the framework design for adverse events and engaging with the SPS and NPrCN on this. Also part of the SPS short life working group considering the review of the DIPLAR process.

Forward look to next steps on implementation of the key recommendation 

Cat Dalrymple provided the group with an update on priorities for progressing the key recommendation over the next 2/3 months.

Group are continuing to make progress. Took a draft “how it could work” to the family workshop which raised 3/4 important questions for group to consider when it next meets. All organisations will need to consider what they need to do to be in a position to do a test of concept. Will also require memorandums of understanding in respect of information sharing to be drafted.

Aspiration to pilot early in the new year. Need to be able to keep demonstrating progress.

Nancy Loucks commented that the family workshop had been very positive in tone and feedback from families was that they felt they were helping getting things moving.

Cat Dalrymple commented that she would require to obtain the Cabinet Secretary’s approve to direct an organisation to conduct the pilot. The pilot would likely just involve one death and an evaluation would require to be carried out.

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

Gillian Imery provided an update. The group met for the third time last week. Unfortunately, the co-Chair Linda Allan has had to step away from that role for personal reasons. Jocelyn Hinds relatively new head of data for SPS and also Amy Wilson, head of Justice Analytic Services at Scottish Government have both joined the group. Felt starting to make progress on gathering data and analysing that to get a better understanding of why deaths are happening in prisons. Clear however still gaps in that data, looking for the group to identify where those gaps are and how the information can be obtained.

Sue Brookes commented that the SPS were looking to extract information from DIPLAR reviews. Also looking to try to get some research capability to assist.

Gillian Imery commented that whilst the wording of recommendation 1.1 was the creation of a “single framework”, there is an acknowledgement that there are so many relevant strategies and policies already in existence. Group are not attracted to coming up with another framework document. Felt the new prisoner healthcare needs assessment documents may play a key role in trying to improve healthcare in prisons.

Nicola Gilroy advised that the prisoner healthcare team were in the very early days of considering all of the recommendations from the healthcare needs assessments. This will be a priority in the new year.

Family engagement

Gillian Imery discussed with the group an increasing awareness of the conflict between family members wanting to contribute to the deaths in custody review work and the impact that has on them. It can particular affect them listening to other people talking about their experience of loss. Having the voices of families, invaluable to progressing the work but difficulty is getting balance without having a negative impact on them.

Nancy Loucks commented that it was a very difficult balance. In her experience families sharing their experiences can be a form of good mutual support. Feedback from families was that they were frustrated with the pace of change. Practical and engagement with tangible outcomes will help maintain participation of families.

Asha Anderson had provided a couple of questions that she had wanted to raise with the group. They related to providing more details about timescales and if families could do anything to assist progress.

Gillian Imery commented that need to find a way to manage expectations of families. Found they have been accepting of realistic discussions. Asha’s questions are indicative of families general frustrations.

Cat Dalrymple and other members of the key recommendation working group recently help a workshop style meeting with the family reference group. Format of that seemed very well received and families commented they would like to work in that style on more of the recommendations. The recommendations relating to DIPLAR suggested as an option and understand that was discussed last week at SPS and could be taken forward.

Sue Brookes also commented that there may be scope to do some practical things with families and have more direct conversations with them, for example showing them the new ligature cutters or speaking to governors about their communications with families. Would be very tricky to manage and would need to be careful about adding to their trauma.

Gillian Imery commented that families have often acknowledged the impact on SPS staff.

Visits with prison governors

Gillian Imery advised the group that recently she’d met with governors at a number of different establishments, HMP Dumfries, Shotts, Edinburgh and HMYOI Polmont. Really grateful for the time that Governors had set aside and for sharing their experiences. Was disappointed that there wasn’t an earlier opportunity to do this earlier. Clear from those discussions, significant impact felt when a death occurs in a prison on both staff and other prisons.

Had been keen progress report had also included the voice of those working in prisons responding to deaths but unfortunately hadn’t been able to get that in time for publication. Gillian Imery further commented that if she is to publish a further progress report before appointment as Chair ends, would be keen to make sure that is included as a more positive perspective. 

Gillian Imery advised that she was attending a Governor in Charge forum meeting later that month. Had been disappointed that the deaths in prison work didn’t seem to be featuring regularly as an agenda item at these meetings given importance of it. 

Any other business

There was a discussion about inviting Wendy Sinclair-Gieben to next meeting to allow her an opportunity to hear first hand about the work of the group and progress. Group agreed to this.


  • COPFS to update group next time more on progress of the MOU between COPFS and SPS and likely timescales for agreement
  • Wendy Sinclair-Gieben to be invited to attend next meeting of DiPCAG
Back to top