Deaths in Prison Custody Action Group minutes: March 2024

Minutes from the meeting of the group on 5 March 2024.

Attendees and apologies

  • Gillian Imery, Gillian Imery, Independent Chair, Oversight of Recommendations of Review into Response to Deaths in Prison Custody 
  • Susan McGregor, Family reference group member 
  • Karen Winning, Family reference group member 
  • Andy Shanks, Crown Office and Procurator Fiscal Service 
  • Debbie Carroll, Crown Office and Procurator Fiscal Service 
  • Cath Haley, Healthcare Improvement Scotland 
  • Craig Sayers, National Prison Care Network 
  • Eilidh Cunningham, National Prison Care Network 
  • Matt Paden, Police Scotland 
  • Nancy Loucks, Families outside 
  • Sheena Orr, Scottish Prison Service Chaplaincy 
  • Siobhan Taylor, Scottish Prison Service 
  • Stephen Coyle, Scottish Prison Service 
  • Alex Doig, Scottish Government 
  • Amy Wilson, Scottish Government 
  • Sarah McQueen, Scottish Government 
  • Cat Dalrymple, Scottish Government 
  • Karen McNee, Scottish Government 
  • Kim Hunter, Scottish Government 
  • Laura Begg, Scottish Government   


  • Sue Brookes, Scottish Prison Service 
  • Suzy Calder, Scottish Prison Service 

Items and actions


The meeting was opened, and apologies were noted. New members were welcomed to the group and were invited to provide introductions around the table.  

Gillian Imery specifically thanked the members of the family reference group for attending this DiPCAG and for sharing their experiences with the motivation of trying to help other families go through the same experiences. Gillian noted that to date there had been 15 deaths in prison so far this year, highlighted the importance of this work. 

Alex Doig, Deputy Director for Prisons, Scottish Government, was identified to chair the DiPCAG group going forward due to Gillian’s time as Independent Chair coming to an end.  

There were no comments on the minute from the previous meeting (November 2023) and these are published on the Scottish Government DiPCAG page. 

Updates since November 2023 

The Family Reference Group met, and Andy Shanks provided an update on the improvements COPFS are making to their processes around deaths in custody.  

Gillian met both Cabinet Secretary for Justice and Home Affairs and the Cabinet Secretary for NHS Recovery, Health and Social Care in November 2023 where the focus was the recommendations shared between the NHS and Scottish Prison Service and described it as a positive meeting.  

Gillian attended the Cross-Party Group on women and girls and the Justice Committee. 

Gillian published her final progress report on 12 February 2024 and Gillian noted her thanks to all agencies for their contributions and support in implementing the recommendations from the Independent Review. Gillian noted that there were eight recommendations complete and two advisory points (and that by the end of this meeting 10 recommendations could be considered implemented). Gillian also highlighted that she feels that scrutiny bodies should be involved in monitoring implementation and changes made. 

Gillian met with Linda Allan, Nancy Loucks, Wendy Sinclair-Geiben, and Sarah at Glasgow University to discuss their publication on deaths in custody including FAIs. 

Gillian will speak to the National Preventative Mechanism on the 7 March and is hoping they take an interest in monitoring changes made going forward. 

Updates on outstanding recommendations  

Key recommendation 

Cat Dalrymple provided an update on the key recommendation. The update included that the first pilot of the draft investigative process took place in September and October 2023. The report from that investigation was shared with organisations the week prior and an evaluation on that exercise has started.   

Another pilot is due to take place on 18th and 22nd of March using an anonymised case which is slightly more complex to further test the process. A wider evaluation will take place following that exercise. The importance of understanding the impact on families was stressed. 

Cat thanked the organisations for their work on the pilot, particular in respect of anonymisation data and for contributing to the evaluation so far. Thanks was given to Families Outside and particularly to Asha from the family reference group who have been involved from a family perspective. 

Following the evaluation a round table would take place to discuss with all parties, including the writers of the original report. 

Gillian highlighted that she was not enthusiastic about this recommendation being implemented and believes it only targets the symptoms of the problem. The main problems are lack of information given to families at the earliest opportunity and the timing, these are the critical parts to solve. This sentiment was echoed by family reference group members. 

Recommendation 1.1 and 3.4 

Eilidh Cunningham provided an update on the Management of Offenders at Risk due to any Substance (MORS) strategy highlighting that it is out for consultation and that they have been given substantial feedback. SPS are going to contribute from an operational perspective. Key deliverables on this are in the workplan. 

Amy Wilson provided an update from Justice Analytical Services (JAS) on data noting that an initial report on analysis of deaths in prison between 2012-2022 which provides context had been published. Amy noted the next report is taking longer than they would like due to data sharing, JAS received the data in January, and they have recruited staff to focus on the deaths in custody work. The next report will include age standardisation and use of the WHO definitions to make comparisons between the general population and the prison population. Amy noted that the next publication will be published in the next few months and there should be an annual publication in future years. The aim is that analysis will be able to help understand why deaths occur in prison and therefore reduce the preventable deaths in prison. 

Recommendations 1.2, 2.1, 2.3, 3.1 and 5.1 

SPS have competed a review of their Death in Prison Learning Audit and Review (DIPLAR). NHS health boards are to implement the toolkit.  

Karen McNee provided an update on Healthcare in Custody including that additional focus has been put on prisons for health boards. Measures include the 24-25 Annual delivery plan includes a specific ask on deaths in custody, the national leads collaborative has been established and will be used as a forum for best practice and includes consideration of the Death in Custody recommendations. The NPrCN are collecting information to use on an ongoing quarterly reporting basis.   

Cath Haley gave insight that Healthcare Improvement Scotland (HIS) as a scrutiny body for inspecting healthcare in prisons completing about 3-4 healthcare inspections every year using set indicators and a framework which now measures against the toolkit (and therefore the recommendations).  

Gillian confirmed that she now considered recommendation 2.3 to be complete.  

Recommendation 1.3 

The SPS concerns phoneline has been introduced and the website has been updated, which is aimed at addressing family concerns and giving feedback to families. The system will be monitored, and an evaluation undertaken. Gillian confirmed that she now considers this recommendation to be implemented.  

Recommendation 3.2 

Andy Shanks provided an update on recommendation 3.2 highlighting that the data sharing agreement between COPFS and SPS is sitting with SPS for final checking. Whilst this does not directly address 3.2 it will have wider system benefits and should allow for earlier provision of information to families. Andy stressed that they are looking at ways to accelerate information flows to give out information to families including in cases where there may be criminality. 

Family representatives asked that they include covering letters on any information that COPFS send out, for example warning the family of the descriptive nature of the DIPLAR/SAER. Although it is noted that this information is contained within the updated Family Support Booklet. 

Recommendation 4.1 

Draft of the new policy is due to be finalised that week. Will then be considered by senior executive team at SPS.  

Recommendation 4.2 

Four trauma informed modules are available for all staff, a specific eLearning module is available for senior managers. These modules should help staff better support those in their care. There is a revision of guidance on escorted absence for funerals/memorials etc. 

Recommendation 5.3 

SPS intend to expand the use of external chairs at DIPLARs however finding a replacement for the current person is challenging. Discussions are ongoing to find something suitable for longer-term. 

Advisory point 1 

SPS and NHS do not believe that the bereavement forum is appropriate for them, instead an initial discussion could take place with the family group to make sure that the resource is as it should be. Nancy Loucks thought that the bereavement forum should be commissioned by the SPS and NHS. 

Advisory point 2 

SPS noted that this requires a significant budget, and their position remains unchanged that they have no plans to progress this.  

Advisory point 3 

SPS believe this has been considered as part of the DIPLAR review, however Gillian does not agree this has been fully addressed. SAER will be reviewed through HIS who are undertaking a SAER review.  

Other business

Police have scheduled another meeting of the death in custody national governance group to improve practice nationally.  

Families thought that more communication should be given to families on the SAER from the NHS to keep them informed. 

Nancy commented that part of the key recommendations was that families should be automatically granted legal aid for the FAI. 

Gillian was thanked for all her work and for holding all organisations to account and carrying out a challenge function with kindness and compassion. 

It was reiterated that Alex Doig would be chairing the DiPCAG going forward. 

Thanks was given to Karen and Susan for their contributions at the meeting and for their continued involvement. 

The meeting was closed. 

Back to top