Publication - Minutes

Deaths in Prison Custody Action Group minutes: June 2026

Published: 19 August 2026
Directorate: Justice Directorate
Topic: Public sector
Date of meeting: 18 August 2026

Minutes from the meeting of the group on 22 June 2026.

Part of

Deaths in Prison Custody Action Group

Attendees and apologies

James McLellan, Scottish Government (Chair)
Lorraine Almond, Crown Office and Procurator Fiscal Service
Eilidh Cunningham, National Prison Care Network
Carron McKellar, Police Scotland
Nancy Loucks, Families Outside
Suzy Calder, Scottish Prison Service
Cara Halliday, Scottish Prison Service
Emma Dilger, Scottish Government
Deanna Francis, Scottish Government
Phoebe Warren, Scottish Government
Emma Young, Scottish Government
Scott Nivison, Scottish Government
Aga Lysak, Scottish Government
Rebecca Smith, Scottish Government
Richard Shearer, Scottish Government
Sarah MacQueen, Scottish Government

Apologies

Karen MacNee, Scottish Government
Sarah Angus, Scottish Prison Service
Sarah Ogilvie, Scottish Prison Service

Items and actions

Welcome and introductions

The Chair welcomed attendees and thanked members for providing written updates to the action plan.

Action points from the January meeting - updates (action owners)

The minutes of the January meeting were accepted as an accurate record.

Nancy reiterated the importance of ensuring that families are involved in memorials. She recalled an example where SPS said they couldn’t engage with the family because they didn’t have their contact details. However, these details must have been available to notify the family of the death in custody. Suzy confirmed that SPS makes all efforts to ensure that families’ contact details are up to date.

Updates on actions in progress were discussed:

Action 1 – follow-up on HIS representation remains in progress. Contact has been made with a Catriona Hutcheson and a response is awaited. Richard might be asked to facilitate the contact if further attempts are not successful.

Action 2 – monitoring arrangements for implemented actions was discussed. The revised action plan template was introduced by the Deaths in Custody Team ahead of this meeting to strengthen oversight, including clearer updates, monitoring arrangements and post‑implementation assurance. It was highlighted that the format is currently complex and may be difficult to navigate as there are many actions in relation to various pieces of work that it can be challenging to separate. Members agreed that it is envisaged that the task will become easier over time once they become more familiar with it. Separating actions agreed as implemented from those outstanding will help. It was agreed that not all fields will always be completed, as updates might not be available. It was agreed this action was closed.

Action 3 – further consideration is required regarding ownership and how best to implement recommendations 1.1 and 3.4, including possible integration with the national oversight mechanism (NOM), which will be discussed under agenda item 3.

Action 4 – at the January meeting it was agreed that the Scottish Government would identify the accountable lead for recommendation 2.5. The Death in Custody Team is liaising with Youth Justice colleagues and confirmed that no under‑18s are held in YOI. Scottish Government involvement is limited as provision sits with independent organisations, however the team is progressing this work to explore available options in more detail. Youth Justice colleagues have agreed to provide some further detail of the steps that are taken and this will be shared with the group members prior to the next meeting in December. This action is now considered closed.

Action: Youth Justice colleagues to provide further information confirming that recommendation 2.5 is implemented and child-friendly policies are in place for under 18s who are sentenced to detention.

Action 5 – completed.

Acton 6 – completed.

Action 7 – Deanna explained that the specification for the Family Advocacy Service could not be amended at the point this action was suggested. Work is ongoing to explore what other options are available to ensure implementation of advisory point 1, discussed under agenda item 3.

Action 8 – completed.

Action 9 – engagement with bereaved families continues to determine preferred communication methods, including family reference groups and written updates. The Deaths in Custody Team maintains and continuously updates the question-and-answer document, which was shared with the families following a meeting with the First Minister in December. It was agreed that it is important to communicate to families the reasons for delays or where actions cannot progress.

Action 10 – JAS update will be provided under agenda item 4. This action is now closed.

Update on recommendations (action owners)

Recommendations implemented

The Chair noted that 19 recommendations and action points had previously been implemented and a further recommendation (4.1) has been reported as implemented since the January meeting. It is a subject to group agreement, and the Chair invited members to provide their update.

Recommendation 4.1 – trauma-informed support

“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.”

Suzy outlined that significant progress has been made through the development and roll-out of a post-trauma and resilience (PT and R) policy, which ensures that staff impacted by traumatic incidents are easily identified and provided with an appropriate follow‑up support.

In addition, the Senior Leader Wellbeing Programme combines group-based resilience sessions with access to confidential one‑to‑one support, including optional clinical support where required. The uptake and engagement with the programme have been positive.

Suzy also confirmed that trauma-informed approaches are being embedded more widely across SPS, for example by increased access to wellbeing resources and support tools, development of guidance materials and training resources. Engagement with staff at different levels is ongoing to support implementation.

Eilidh confirmed that trauma‑informed practice across NHS is being supported through the Deaths in Custody Support Toolkit and wider workforce development processes. This includes embedding trauma‑informed training within Personal Development Plans, promotion of national trauma training programmes and ongoing monitoring through management engagement, including regular 1:1 discussions between staff and line managers.

It was noted that both SPS and NHS have mechanisms in place to monitor and assure delivery of trauma‑informed support, although detailed quantitative data is not available.

Members agreed that recommendation 4.1 can be considered implemented, recognising that this is an area of continuous development and that further refinement and embedding of trauma‑informed practice will continue over time.

Recommendations in progress

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.”

Deanna confirmed that both recommendations now sit with the Scottish Government and provided an update on the work, including exploring feasibility of the NOM supporting delivery.

It was confirmed that despite resource constraints and the post‑election uncertainty, work is ongoing and a more robust update on what is possible and what it outwith the NOM scope will be available ahead of the December meeting. Similarly, progress has been made in the development of the Family Advocacy Service, however, due to the commercial sensitivity, specific details could not be shared with the group at that point in time.

Lorraine highlighted that clarity on NOM development would be helpful for COPFS’ own planning, and asked to see the NOM ToR once finalised, so COPFS could consider the terms of references for their own work planning.

Action 2: Scottish Government to share a copy of the finalised NOM ToR with COPFS and arrange a meeting to discuss them.

It was confirmed that the implementation of the recommendations from the Independent Review of Fatal Accident Inquiries 2025 Report by Shariff Abercrombie is led by Walter Drummond-Murray and his Fatal Accident Inquiry Review Team, with Deaths in Custody Team responsible for some recommendation with links to NOM and Family Advocacy Service.

Deanna also confirmed that there was going to be a Family Reference Group meeting on 26 June 20206 and invited members to use it as an opportunity to share updates or ask questions.

Action 3: Scottish Government to provide an update on recommendations 1.1 and 3.4.

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.”

Suzy outlined that a programme of work is underway to strengthen communication arrangements with families. This includes a comprehensive gap analysis to identify areas for improvement in existing processes and guidance. The outcome of this work will inform a set of prioritised actions, with clear objectives and timescales expected to be defined around September.

She also confirmed that the Family Support Booklet is undergoing a full review, which includes a review on language used and references to the Significant Adverse Event Reviews. It has involved consultation with key stakeholders, including NHS, Families Outside, and the Family Reference Group.

Eilidh confirmed that NHS is fully committed to compassionate and trauma-informed communication. Any improvements are supported by NHS Education Scotland training.

There is currently a high level of variation of how the deaths in custody are investigated across NHS Boards. Whilst some Boards undertake a Significant Adverse Event Review (SAER) following a death in custody, others carry out a local review process. The Prison Care Network is undertaking a mapping exercise to better understand what is happening in across the Health Boards. It was agreed that this information would be shared with families at the next Family Reference Group.

It was agreed that recommendation 3.2 remains in progress, with work underway. Further updates, including outputs from the gap analysis and Bereavement Care Working Group, are expected to provide greater clarity on next steps and delivery timelines.

Advisory point 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.”

As discussed under agenda item 2, the Family Advocacy Service specification could not be amended to incorporate the delivery of this advisory point. Scottish Government confirmed that further work is required to determine whether this advisory point remains implementable.

It was noted that engagement with families has indicated some interest in peer support and shared spaces to process experiences, although needs may vary and not all families may wish to engage in the same way. It was agreed that additional scoping work is required to better understand demand, identify gaps in current support, and ensure any future approach is trauma‑informed and accessible.

This advisory point remains in progress, with further updates to be provided ahead of the December meeting.

Action 4: Scottish Government to provide an update on advisory point 1.

Advisory point 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.

In response to the FAI recommendations, wider work is now underway, considering digital options and the broader cell environment. In addition to this work, a short life working group (SLWG) has been established to review the Emergency Response policies comprising five NHS Boards and the Scottish Ambulance Service to strengthen joined up processes, with work due to conclude in quarter 2 of 2026. There may be some recommendations that stem from the SLWG and work is being developed at pace to provide assurances around how SPS respond to emergencies. Support plans for individuals at higher risk of health incidents are also being developed and will remain under review.

Advisory point 2 remains in progress, and further update will be available ahead of the December meeting.

Justice Analytical Services update (Sarah MacQueen)

The Chair invited Sarah MacQueen to provide an update on the work of Justice Analytical Services (JAS). He apologised for insufficient time to cover this item at the previous meeting.

Sarah outlined that JAS work on deaths in custody originated from a DiPCAG subgroup established to address gaps in data and analysis, which had been identified as a barrier to progressing several of the Independent Review recommendations. The analytical programme aims to improve understanding of trends and support evidence‑based policy development on death prevention.

She advised that JAS has published analytical reports covering deaths in custody over the past decade, providing high‑level statistical analysis and trend data. These publications are intended to improve transparency and provide a more consistent evidence base to inform policy and operational decision‑making. Improvements in data sharing arrangements, particularly with National Records of Scotland, have strengthened the quality and scope of analysis. This has enabled more robust reporting and greater insight into patterns and causes of deaths in custody over time. Key findings from the analysis include:

the period 2023–24 recorded the highest number of deaths in prison custody
the majority of deaths occur within the male prison population
suicide remains the leading cause of death in custody and is statistically higher than in the general population
deaths related to drug misuse are broadly comparable to rates in the general population
cardiovascular disease is also a significant contributing factor

JAS emphasised that the analysis is currently presented at a high level, focusing on trends rather than individual cases, in line with data protection considerations and the intended purpose of the publications.

It was noted that there are still gaps and limitations in available data, and JAS is working with SPS and other partners to improve the granularity of data and consistency across datasets. Work is ongoing to update data sharing agreements to enable access to more detailed information, including the specific substances involved in drug‑related deaths. This is expected to support a more detailed understanding of trends and inform targeted interventions.

It was noted that JAS is currently operating with reduced capacity due to staffing pressures, which may impact the pace of future analytical work. Recruitment is ongoing as well as the accreditation process, which will improve transparency of data analysis.

The Chair recognised the value of JAS analysis in supporting the Group’s objectives and the importance of continued analytical development to support delivery of the Group’s wider objectives, including informing work on Recommendations 1.1 and

Deanna confirmed that she and the Death in Custody Team are already liaising with JAS.

Any other business, and close

James thanked all for the constructive discussion and confirmed that the next meeting is scheduled for 1 December 2026.

He invited members to consider future governance and assurance arrangements, including the role of Scottish Government, NOM and the Family Advocacy Service in overseeing delivery.

Action 5: Members to consider future governance and assurance arrangements, including the role of Scottish Government, NOM and the Family Advocacy Service in overseeing delivery.

Actions

Action 1: Youth Justice colleagues to provide further information confirming that recommendation 2.5 is implemented and child friendly policies are in place for under 18s who are sentenced to detention.