Deaths in Prison Custody Action Group minutes: March 2023

Minutes from the meeting of the group on 29 March 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
  • Wendy Sinclair-Gieben, HM Chief Inspector of Prisons
  • Cat Dalrymple, Deputy Director, Community Justice, SG
  • Suzy Calder, Interim Head of Health, SPS
  • Sue Brookes, Director of Strategy and Stakeholder Engagement, SPS
  • William Stewart, Governor, HMP Shotts, SPS
  • Catherine Haley, Senior Inspector, 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
  • Debbie Carroll, Heath of HSIU, COPFS
  • Nicola McAndrew, Team Leader, Prisoner Healthcare, SG
  • Laura Begg, Community Justice, SG


  • Asha Anderson, representative for families bereaved by a death in prison custody
  • Sheena Orr, Chaplaincy Advisor, SPS
  • Stephanie Blair, Principal Procurator Fiscal Depute, COPFS
  • Nicola Gilroy, Senior Policy Officer, Prisoner Healthcare, SG

Items and actions


Gillian Imery welcomed everyone to the fourth meeting of the DiPCAG. William Stuart, Governor in Charge at HMP Shotts was welcomed to the group as a representative of Prisoner Governors. Wendy Sinclair-Gieben, HM Chief Inspector of Prisons was also welcomed to the meeting, having been invited as one of the co-authors of the Independent Review to hear first-hand updates on progress. 

Minutes of last meeting and update on actions

No comments were received on the minutes of the last meeting. They have now been published on the SG website.

Two actions from previous meeting:

  • COPFS to update group next time more on progress of the MOU between COPFS and SPS and likely timescales for agreement

Katrina Park updated the group that this was progressing but that there was a question over the terms of the MOU. There had been a number of hurdles to completion which had been ongoing since 2019.

Katrina Parkes and Suzy Calder agreed to follow up on this to try to improve progress.

  • Wendy Sinclair-Gieben to be invited to attend next meeting of DiPCAG

Gillian Imery commented that she was pleased that Wendy has been able to make it to the meeting today and hoped that she would benefit from hearing first hand about progress.

Reaction to progress report and transparency on future progress

Gillian Imery reminded the group that her progress report had been published on 14th December and was a candid reflection of her views on progress. She advised the group that she had provided verbal updates to the Cabinet Secretaries for Health and Justice who had jointly written to Chief Executive of SPS and all NHS Scotland Chief Executives and Integration Authorities Chief Officers requesting that greater priority be given to timely implementation of the recommendations.

Gillian Imery expressed the view that there appears to be an appetite from Ministers to help remove inhibitors to progress. A prison healthcare short-life strategic leadership group has been established with strategic leaders from across the system to provide impetus, action and direction with the aim of resolving these challenges.

Nicola McAndrew offered to help facilitate Gillian Imery being invited to a meeting of the group.

Gillian Imery advised the group that there has been increased parliamentary interest in the work of the group and the work of the group is under scrutiny and important to keep momentum going.

Gillian Imery advised the group that she had been invited to a Prison Governors in Charge (GIC) Forum meeting in late December. GIC were keen to discuss the progress report and ways in which they could be more involved. Acknowledged that they have an important role in leading and implementing changes in practice and culture. Pleased to now have a representative of Prison Governors on this group to help strengthen work of the group into changes in practice. 

William Stewart advised that whilst he hadn’t been able to attend the meeting, he had noted that it had been commented that it was a surprise that DiPCAG work was not a standing item. From his point of view he felt there was movement on progress and he was involved in some of the SPS working groups.

Gillian Imery advised the group that she intends to provide the Cabinet Secretaries with an update on progress in summer. Hope to be able to report on more significant progress by then. Also plans to publish a “closure report”. Doesn’t expect to be able to report that all of the recommendations are complete but will be another written report in the public domain around the 2 year anniversary of publication of the Independent Review. The group were reminded that for some of the families, they had been involved for a lot longer than 2 years.

Forward look to next steps on implementation of recommendations (Scottish Prison Service; NHS – National Prison Care Network; NHS – Healthcare Improvement Scotland; Crown Office and Procurator Fiscal Service; Police Scotland)

Gillian Imery thanked those who provided updates in advance of the meeting.

Suzy Calder provided an update on behalf of the SPS. In December, the SPS had identified as their priorities, the recommendations relating to the DIPLAR process, review of the Critical Incident Response and Support (CIRS) process and the family support booklet. Suzy Calder thanked the family reference group for their input to the DIPLAR review and family support booklet.

The electronic concern form was still available but hasn’t been rolled out beyond initial touch points. A review of the front facing website is to be undertaken. Initial drafting of a “how to raise a concern” booklet was being undertaken and more work to be done on this. An audit test was undertaken in respect of concerns being raised by telephone. This identified a number of areas that need improvement. It is being considered whether a dedicated telephone number for raising concerns can be introduced to allow families to contact SPS directly and staff processing these calls will prioritise them.

In respect of the review of the DIPLAR process, a significantly different review document has been produced. This has been widely consulted on and confident now at a stage that meets relevant recommendations. Guidance document is being redrafted to be more of a “how to do” document. Hoping to test new paperwork in April. This has been a significant piece of work.

In relation to the new ligature cutters, there had been a delay in receiving the full order but pleased to report they have now been received. They will be delivered to the establishments once there is confirmation that training has been carried out and that risk assessments have been undertaken.

Leadership trauma training was being undertaken and current second cohort are mid-way through their training. Chaplaincy team are also working with Governors in Charge in relation to communicating with bereaved relatives.

The family support booklet is close to completion and needs to undergo accessibility/equality checks. Input on this document had been received from the family reference group on aspects such as language, format, layout and content.

Gillian Imery commented that at the suggestion of the Governor at HMP Edinburgh she recently met with the manager of the family visitor centre there. Clear from that discussion that families still struggle to know where to turn to if they have concerns about someone in prison. She also commented that she was very encouraged by the DIPLAR review that is being undertaken and the meaningful consultation that was undertaken with the family reference group. Feedback had been received from families that they felt heard and amendments were made based on their feedback.

Stewart Taylor commented that families were pleased to see progress being made in respect of the review of the DIPLAR process and that more consideration was being given to supporting staff in the prisons.

There was a discussion about the role of NHS in DIPLARs. It was commented that this in practice had never really been a joint process. That NHS will continue to engage with the DIPLAR but don’t see it as their primary process for learning. Craig Sayers acknowledged that there was a need for more consistency in the SAER process across the prison estate and to ensure families were involved and reports shared with them. Suzy Calder commented that it was important that if at a DIPLAR appropriate actions are identified for the NHS that shouldn’t be lost and there was often a need for joint learning. It was felt there needed to be clarity on the point when these documents were shared with families and made available for FAIs.

Nancy Loucks commented that she welcomed the news that other means of reporting concerns were being considered but cautioned that Safer Custody telephone lines had been introduced in England but there were issues with these not always being staffed and messages not being checked.

Craig Sayers provided an update on behalf of the National Prison Care Network.

In respect of prevention work, key areas had been identified to address over the next 12 months. Working with COSLA, PHS and SG in relation to the capturing of data for suicides and drug related deaths. Looking at how to manage patients suspected of intoxication. Been speaking to the Royal College of Emergency medication to better give nurses tools to assess those who are intoxicated and how to manage them. In relation to deaths by suicide, identified some inaccuracies in data so working with the SPS on that. Feeling that there needs to be a smoother process for transferring people to psychiatric care for assessment.

The GP Forum has been considering chronic disease management. Awareness that this is poorly managed and data poor. In relation to diabetes working with experts and PHS on improved healthcare.

In relation to the confirmation of death process. A training video was recorded in February which has now been edited and needs some further revisions before going live. Healthcare teams have advised that they need 6 months to complete training of all staff. After 3 months the National Prison Care Network will look at data on training completion rates. Nurses will refresh the training every two years and will be given competency card to carry around as a reminder.

Significant work has been done on the trauma informed care framework. Currently getting feedback from psychology colleagues. Framework goes beyond the recommendations and if it were to be mandatory would require significant investment.

Cath Haley advised that there were no significant updates to provide on behalf of Healthcare Improvement Scotland.

Katrina Parkes provided an update on behalf of COPFS.

The Scottish Fatalities Investigation Unit is looking at ways of continuous improvement. The deaths investigation improvement programme is now focusing on listening to families and is setting up a lived experience panel. The website is being updated and a FAI pack is being created.

Matt Paden provided an update on behalf of Police Scotland.

Internal briefing has been conducted at a senior level around the role of the SOIP. Considers there is a need to establish a Death in Custody Operational Group to ensure Police Scotland, SPS and COPFS develop effective processes, governance structures and communication in respect of investigations into all aspects of deaths in custody. Seeking to identify single points of contact to be representatives on behalf of Police Scotland for the SOIP process. Also looking internally at information sharing and discussing this with information management colleagues.

Forward look to next steps on implementation of the key recommendation

Cat Dalrymple provided an update on the work to progress the key recommendation.

The working group had a constructive meeting when they last met on 28 February.

Received a presentation from colleagues at the Mental Welfare Commission in respect of investigations of deaths of people in mental health detention. Although different parameters, lots of areas of crossover.

Working group have created a draft process that all relevant organisations have agreed to. Recognised that there are challenges and all organisations have been asked to provide information by 4th April about any internal steps need to undertake to start a pilot.

Residual concern about involving families in an untested process and potential for causing harm. Need to speak to all of the organisations and also family reference group about a suggestion that may make pilot simpler. Keen to drive forward but also want to be realistic. Not currently at stage ready to pilot. Want to test processes and timescales.

Gillian Imery queried whether the group were confident the pilot could commence in June. Cat Dalrymple advised that SG were relying on the other organisations to ensure that they have all processes in place that are required for the pilot and that would affect when pilot could commence.

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

Gillian Imery updated that the working group has met on one further occasion since the last DiPCAG meeting. Focus still on how to improve quality of data around deaths to better understand why deaths happen all to try to contribute to reducing deaths in the future. Pockets of progress have been made by the SPS and National Prison Care Network. It has been agreed that a data and evidence group will be established, chaired by the Head of Justice Analytical Services. The group will explore the possibilities for further enhancement of data, develop a workplan for deliver on these enhancements and provide peer review to analysis carried out by individual organisations.

Sue Brookes advised that the Head of Research at the SPS was undertaking a review of DIPLARs which is a significant piece of work and likely to take three to six months.

Update from family reference group

Stewart Taylor advised that the family reference group are generally happy with recent progress and want everyone to keep momentum going.

Gillian Imery provided the group with some feedback on behalf of Asha Anderson. Asha had comment that she had found the last family reference group meeting to be positive as she felt that families had been heard in amending and improving the process/documentation. Asha encouraged other DiPCAG members to attend and speak to the family reference group about work they were engaged with and ask questions of families that could play a part in improving the death in custody approach.

Gillian Imery asked the group to think about pieces of work they were progressing that families could contribute to and provide feedback on. 

Any other business

Wendy Sinclair-Gieben commented that she was delighted to see and hear that so much work was being undertaken to progressed. She would like to see the prevention work receiving some more momentum and progress being made on a simpler process for family members to report concerns about someone in prison.

Gillian Imery advised that the next meeting was likely to be in mid/late June and a request for people to attend in person if possible as that would be around one year since the group was established.

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