Deaths in Prison Custody Action Group minutes: January 2026

Attendees and apologies

• James McLellan, Scottish Government (Chair)
• Lorraine Almond, Crown Office and Procurator Fiscal Service
• Andy Shanks, Crown Office and Procurator Fiscal Service
• Eilidh Cunningham, National Prison Care Network
• Craig Sayers, National Prison Care Network
• Moira Manson, Healthcare Improvement Scotland
• Carron McKellar, Police Scotland
• Nancy Loucks, Families Outside
• Sam Jelf, Families Outside
• Sarah Angus, Scottish Prison Service
• Suzy Calder, Scottish Prison Service
• Susan McKerracher, Scottish Prison Service
• Cara Halliday, Scottish Prison Service
• Emma Dilger, Scottish Government
• Phoebe Warren, Scottish Government
• Aga Lysak, Scottish Government
• Rebecca Smith, Scottish Government
• Richard Shearer, Scottish Government
• Sarah MacQueen, Scottish Government
• Jamie Stewart, Scottish Government

Apologies:

• Karen MacNee, Scottish Government  
• Deanna Francis, Scottish Government  
• Michael Cairns, Scottish Government  ​​​​​​​

 

Items and actions

Welcome and Introductions

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

Chair’s update (James McLellan)

James McLellan, Deputy Director for the Prisons and Release Division, introduced himself and welcomed new members.

The group acknowledged the importance of maintaining momentum, particularly in light of recent work related to the Cabinet Secretary for Justice and Home Affairs commitments, which align closely with the independent review’s recommendations.

James outlined the purpose of the meeting: to take stock, review outstanding recommendations, agree on a delivery approach, and consider next steps.

It was noted that Moira Manson is leaving Healthcare Improvement Scotland (HIS), resulting in a temporary gap in representation.

Action:

• Scottish Government to arrange a follow‑up discussion with Moira regarding HIS representation.

Updates on the Recommendations (Action Owners)

The group agreed to focus discussion on the actions that remain outstanding, based on the returns received and recent engagement. Action owners were invited to provide updates, noting that some actions may have been completed in the interim. The discussion sought to establish which actions are still outstanding, clarify next steps, and resolve any uncertainties around ownership, as well as agree on realistic timescales for delivery.

Nancy sought reassurance that recommendations marked as implemented will continue to be actively followed up and monitored. Emma agreed, emphasising the need to embed routine monitoring and assurance into ongoing oversight work.

Action:

• Scottish Government to consider monitoring arrangements for actions marked as implemented and explore whether this can be incorporated into wider oversight work.

Recommendations 1.1 and 3.4

“Leaders of national oversight bodies (Healthcare Improvement Scotland/NHS boards/Care Inspectorate/National Suicide Prevention Leadership Group/HMIPS) should work together with families to support the development of a new single framework on preventing deaths in custody.”

“To support compliance with the state's obligation to protect the right to life, a comprehensive review involving families should be conducted into the main causes of all deaths in custody and what further steps can be taken to prevent such deaths.”

The group reviewed progress on Recommendations 1.1 and 3.4. While JAS work has established an agreed dataset and increased transparency, members were asked to consider what further action is required to fully meet the recommendations.

Moira highlighted related activity, including publication of the SAER framework with a strong focus on patient and family engagement, noting the Cabinet Secretary’s direction to embed this approach and ongoing evaluation work. A wider 'state of the nation' report is expected by March 2026 as the model shifts towards assurance.

Sarah raised concern that current work focuses on post‑death processes rather than prevention. SG colleagues agreed, emphasising that while JAS outputs are valuable, they do not meet the preventative intent. The developing National Oversight Mechanism (NOM) was identified as a key opportunity to strengthen prevention through thematic analysis and actionable learning.

Sarah and Craig supported deeper, forward‑looking analysis, stressing the need for central collation and sharing of themes across  Significant Adverse Event Reviews (SAERs), Fatal Accident Inquiries (FAIs), Death in Prison Learning, Audit and Reviews (DIPLAR) and other reviews. Members suggested linking this work with the NOM to ensure Recommendations 1.1 and 3.4 are met.

Action:

• Scottish Government to consider linking the work on Recommendations 1.1 and 3.4 with the development of the NOM and provide an update back to the group.

Recommendation 2.5

“The SPS and NHS must ensure that child-friendly policies and practices are introduced and applied to all children, aged under 18, in accordance with the UNCRC. Reviews of deaths in custody involving a child or young person must include an assessment of whether or not the particular rights of children were fulfilled, with child-friendly policies and procedures followed in practice.”

Whilst this recommendation has been marked as implemented, Nancy queried whether responsibility for this and ensuring standards are maintained has officially been handed over to the Youth Justice colleagues within the Scottish Government. It was briefly discussed and identified that there is a gap in clarity around ongoing ownership and accountability.

Action:

• Scottish Government to identify the accountable lead for this recommendation going forward and communicate to the DiPCAG.

Recommendation 3.2

“SPS and NHS should review internal guidance documents, processes and training to ensure that anyone contacting family is clear on what they can and should disclose. SPS should work with COPFS to obtain clarity as to what can be disclosed to family without prejudicing any investigation, taking due account of the need of the family to have their questions about the death answered as soon as possible.”

The group discussed the challenges around improving the disclosure of information to families following a death in custody. SPS noted that while they share DIPLAR information, families often feel it adds little to what they already know, and highlighted legislative constraints, particularly duty of candour, which limits what can be shared. Nancy reported cases where families were not informed that a DIPLAR had taken place at all.

Sarah outlined progress through strengthened governance, updated policy and engagement with family groups, emphasising the need for better collaboration across agencies and the role of the SG working group in supporting this. Andy welcomed the renewed focus, noting initial emphasis on inter‑agency information flow rather than communication with families, and highlighted positive progress, though stressing this must remain an ongoing, iterative process, especially in light of the FAI review.

Sam and Craig reiterated ongoing concerns, that families often have to piece events together themselves, experiences remain inconsistent, and longstanding issues around inadequate information and perceived lack of independence persist. They noted the need for greater consideration, cultural change, clearer timelines, and clarity on what future arrangements will look like as work on the NOM and FAI review work progresses.

James acknowledged the complexity and emphasised that the core issue is ensuring families receive information at the earliest possible stage. While legal constraints exist, the focus should be on understanding current processes, how they operate, and where improvements can be made. He noted links to family advocacy work and suggested background work to break this into clearer elements and consider how progress is tracked, noting that the current tracker does not fully reflect the position and should be refined to support monitoring of this recommendation.

Action:

• Action owners to ensure action plan sets out latest progress.

Recommendations 4.1 and 4.2

"NHS and SPS should develop a comprehensive framework of trauma-informed support with the meaningful participation of staff, including a review of Critical Incident Response and Support policy, to ensure accessibility, trained facilitators, and consistency of approach. This should ensure staff who have witnessed a death always have opportunity to attend and that a system of regular and proactive welfare checks are made."

“SPS and NHS should also develop, with the meaningful participation of people held in prison, a framework of trauma-informed support for people held in prison to ensure their needs are met following a death in custody.”

Eilidh highlighted the NHS Board‑wide commitment to roll out trauma‑informed care training, which is included within the toolkit. The toolkit has recently been reviewed, and communication with staff was identified as an area to strengthen. NES training is available to support this commitment, and NHS consider that, with the toolkit and training provision, this is as far as the network can take the recommendation. Eilidh also noted that trauma‑informed training and expectations around completion are embedded within local personal development plans, ensuring consistent uptake.

Sarah noted that SPS have a framework for all staff, as well as for senior managers. Nancy asked whether SPS had received feedback from staff who have experienced a death in prison. Suzy confirmed there will be an evaluation of staff support, particularly for Governors, noting the feedback informs future support.

Both SPS and NHS requested that this recommendation be considered implemented, and the Chair was content to note it as implemented.

Action:

• Action owners to ensure action plan is as up to date as possible.

Recommendation 5.3

“A truly independent chair, with knowledge of the prison, health and social care environments, should be recruited to chair all DIPLAR meetings providing the assurance that all deaths in custody are considered for learning points.”

Suzy confirmed that four independent chairs, each bringing varied professional senior backgrounds, were recruited and have been in post since September/October chairing DIPLAR’s. Governance arrangements, including trackers and an assurance group, are in place to provide objective oversight. The group agreed this recommendation can be considered implemented and will continue to update members on progress.

SPS requested that this recommendation be considered implemented, and the Chair was content to note it as implemented.

Advisory 1

“A platform should be available for families to share and process their experiences such as a Bereavement Care Forum as previously recommended. The NHS and SPS should commission the independent development and support of such a platform.”

The group discussed the advisory recommending a bereavement platform for families, commissioned independently by NHS or SPS. Nancy noted that neither see this as within their remit, though it needs a clear home, potentially within the new Family Advocacy service.

Sarah confirmed that SPS is not best placed to deliver a family‑focused bereavement platform and agreed the Advocacy service could be explored. She highlighted work in HMP Edinburgh linked to the bereavement charter, including training and a new “waterfall café”, which may begin to link with family support. Nancy welcomed the prison‑based work but stressed the advisory point calls for commissioning by SPS/NHS, not direct delivery.

Members agreed there is a need to clarify what 'commissioning' would mean and whether this function should sit within the Family Advocacy service or another bereavement organisation. Emma noted families’ differing needs and that Scottish Government will consider this within the Advocacy remit.

Craig noted that SPS and NHS have previously advised this is not within their remit to commission or monitor, and early discussions highlighted risks with an online platform, suggesting in‑person options may be more suitable.

The group agreed there is no shared definition of a 'forum', and bereavement support could take multiple accessible forms, online, in person, or hybrid.

Action:

• Scottish Government to explore whether Advisory Point 1 can be addressed through the development of the Family Advocacy Service.

Advisory 2

“The SPS should review the scope to place emergency alarms within reach of the cell bed to ensure the ability to raise the alarm when incapacitated.”

 Suzy updated the group on the review of emergency alarm placement within reach of beds. It was noted that initial findings show that installing a bedside button alone would not be sufficient. A wider review is now underway, considering digital options and the broader cell environment. A short‑life working group comprising five NHS Boards and the Scottish Ambulance Service has been established to strengthen joined‑up processes, with work due to conclude in quarter 2 of 2026. Support plans for individuals at higher risk of health incidents are also being developed and will remain under review.

Nancy asked whether emerging technology previously prioritised for safer cells was intended for wider rollout. Sarah highlighted the distinction between health‑monitoring tools and digital monitoring technologies, noting that early-stage pilots, such as signs‑of‑life technology, require careful evaluation. She noted that although the advisory’s intent is reasonable, it proposes a solution without clearly identifying the core problem. Sarah confirmed that emergency alarms will not be installed beside all beds.

Action:

• SPS to provide DiPCAG members with an update following the conclusion of the short life working group. 

Advisory 3

“SPS and NHS to consider whether other people held in prison who knew the deceased may have relevant information to offer and how best to include their reflections in DIPLAR and SAER processes where appropriate, in particular whether discrimination of any kind was perceived as a factor in the death.”

The group discussed how information from individuals in prison who knew the deceased could be incorporated into DIPLAR and SAER processes. Suzy confirmed that the DIPLAR process already enables this, capturing relationships and relevant reflections from others in custody, and emphasised the importance of ensuring this aspect is not overlooked.

Craig noted that SAER is a standard NHS‑wide process applied consistently across all settings, including prisons, and therefore cannot be adapted specifically for this context. However, the Adverse Event Review team have the capacity to speak to people relevant to the SAER, such as others in prison known to the deceased.

SPS requested that this recommendation be considered implemented, and the Chair was content to note it as implemented.

Advisory 6

“The SPS should develop clear protocols for memorial services, letters of condolence and donations from people held in prison for families of the deceased.”

Nancy highlighted the importance of clearly communicating memorial service plans to families. Suzy confirmed that families are always considered when organising memorials and emphasised the need to maintain focus on the significance of memorials, condolence letters, and related protocols.

SPS requested that this recommendation be considered implemented, and the Chair was content to note it as implemented and kept regularly under review.

Update from Scottish Government on Key Recommendation (Deaths in Custody Team)

“A separate independent investigation should be undertaken into each death in prison custody. This should be carried out by a body wholly independent of the Scottish Ministers, the SPS or the private prison operator and the NHS.”

Emma provided an update highlighting the Cabinet Secretary’s 2025 letter to the Criminal Justice Committee setting out the Government’s position on the Key Recommendation. She noted that while the oversight ambition of the Key Recommendation remains essential, its aims will be achieved through alternative mechanisms. Ministers have agreed to progress reforms under three main pillars, including a review of the FAI process chaired by Sheriff Principal Abercrombie. His report, published on 15 January 2026, will be carefully considered before a further update is provided.

The second pillar is the Cabinet Secretary’s commitment to establishing a NOM. The NOM is currently in development and different delivery models are being considered and will be supported by interim arrangements. The NOM aims to identify trends and drive systemic improvement. Independence and accountability remain central. The aim is to establish interim arrangements ahead of the pre‑election period, with longer‑term options under development.

A further commitment was made to establishing a Family Advocacy Service. The introduction of an independent, trauma‑informed service is currently moving through the procurement process. Emma noted that the Key Recommendation will be implemented, though not in the exact form originally written.

It was highlighted that the First Minister met bereaved families in December and subsequently wrote to them, including a Q and A covering NOM, Family Advocacy, and Crown Immunity. The Scottish Government will assess how helpful this has been and consider providing regular updates to families. Nancy welcomed the idea of ongoing communication, noting that families engage in different ways and that multiple communication approaches will be required.

Action:

• Scottish Government to consider communication mechanisms for bereaved families.

Justice Analytical Services (JAS) update

Given the limited time available, it was agreed that the JAS update would be shared via correspondence, with any further questions to be taken forward at the next DiPCAG meeting.

Action:

• JAS colleagues to circulate the publication and provide the wider JAS update.

Next Steps

The group discussed the broader oversight landscape, noting multiple overlapping workstreams, including this group’s role, the SPA review, and various sets of recommendations emerging across related areas. The FAI work is currently overseen by the Ministerial Accountability Board (MAB). As that winds down, some recommendations will still be outstanding. There is a need to consider future governance and assurance arrangements to ensure coherent oversight and avoid duplication across groups. Given the amount of activity and changes over time, members were invited to reflect on possible models. This will be picked up again at the next meeting.

AOB and Close

Chair thanked everyone for their attendance and contributions.

Actions

Action 1: Scottish Government to arrange a follow‑up discussion with Moira regarding HIS representation.

Action 2: Scottish Government to consider monitoring arrangements for actions marked as implemented and explore whether this can be incorporated into wider oversight work.

Action 3: Scottish Government to consider linking the work on Recommendations 1.1 and 3.4 with the development of the NOM and provide an update back to the group.

Action 4:  Scottish Government to identify the accountable lead for recommendation 2.5 and communicate to the DiPCAG.

Action 5/7: Action owners to ensure action plan sets out latest progress.

Action 6: SPS to provide an update on recommendation 4.1 at the next DiPCAG.

Action 8: Scottish Government to explore whether Advisory Point 1 can be addressed through the development of the Family Advocacy Service.

Action 9: SPS to provide DiPCAG members with an update following the conclusion of the short life working group. 

Action 9: Scottish Government to consider communication mechanisms for bereaved families.

Action 10: JAS colleagues to circulate the publication and provide the wider JAS update.