Deaths in Prison Custody Action Group Minutes: November 2023

Minutes from the meeting of the group on 7 November 2023

Attendees and apologies

  • Gillian Imery, Independent Chair, Oversight of Recommendations of Review into Response to Deaths in Prison Custody
  • Kerry Knox, Head of Family Support, Families Outside
  • Cat Dalrymple, Interim Director, Justice, SG
  • Quentin Fisher, Interim Deputy Director, Community Justice, SG
  • Suzy Calder, Interim Head of Health, SPS
  • Sue Brookes, Director of Strategy and Stakeholder Engagement, SPS
  • 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
  • Andy Shanks, Head of Scottish Fatalities Investigation Unit, COPFS
  • Nicola McAndrew, Team Leader, Prisoner Healthcare, SG
  • Kim Hunter, Community Justice, SG
  • Laura Begg, Community Justice, SG


  • Catherine Haley, Healthcare Improvement Scotland
  • Sheena Orr, Chaplaincy Advisor, SPS
  • Stewart Taylor, representative for families bereaved by a death in prison custody
  • Asha Anderson, representative for families bereaved by a death in prison custody
  • Debbie Carroll, Head of Health and Safety Investigation Unit, COPFS
  • Nancy Loucks, Chief Executive, Families Outside

Items and actions


Gillian Imery welcomed everyone to the sixth and likely final meeting of the DiPCAG. Gillian commented that she had been brought in as an external Chair in April 2022 for 12-18 months to give focus to the recommendations and she is now due to exit that role at the end of the year. Gillian thanked everyone for their work and support.

Gillian welcomed Kerry Knox from Families Outside to the meeting on behalf of Nancy Loucks. 

Minutes of last meeting and update on actions

Gill commented it had been great to see people in person at the last meeting of the DiPCAG.

No comments were received on the minutes of the meeting and they have been published on the DiPCAG page on Scottish Government website.

No actions from last minutes.

Chair’s Update

Gillian provided an update on her actions since the previous DiPCAG meeting on 11 July.

Family reference group has met twice with good input from both the SPS and NHS. Family reference group works best if someone comes along to share their updates and the group can ask questions. Andy Shanks is willing to come along to next meeting of the family reference group to talk about the work COPFS are doing.

At the end of September, Gillian gave a presentation to a National Preventative Mechanism roundtable across the UK on preventing deaths in custody. Some very interesting inputs from academics and bodies who undertake investigations into deaths in prison custody in other UK jurisdictions.

Appeared at the Scottish Parliament’s Criminal Justice Committee on 20 September. Tried to focus on the perspectives of families, expressed disappointment at pace of implementation and expressed view some actions could be progressed more quickly. Highlighted good work of the National Prison Care Network and challenges of translating that to change on the ground. Commented on perceived shortcomings of the FAI process, in particular time to conclude and quality of communication. Also commented on lack of scrutiny of healthcare in prisons.

Met with the Cabinet Secretary for Justice and Home Affairs on 25 October. Very interested in this work, quality of healthcare in prisons and what can be done to change the culture to ensure families are more involved.

Due to have a joint meeting with Cabinet Secretary for Justice and Cabinet Secretary for Health on the 21st November.

Have been asked to provide an update to the Cross-Party Group on Woman, Families and Justice in early December.

Plan to publish another progress report before role comes to an end. Thanked those who provided updates in advance of today’s meeting and some additional information is being sought for some updates. Want to ensure report is best representation of work completed and what next steps are. In preparing the progress report, speaking to individuals who are responsible for implementing changes on the ground to hear first hand the impact of the changes, including prison governors, non-exec director who chairs the non-natural cause deaths and prison officer association representatives.

Update on implementation of recommendations (Scottish Prison Service; NHS – National Prison Care Network; Crown Office and Procurator Fiscal Service; Police Scotland)

Sue Brookes provided an update on behalf of the SPS of work that had been progressed.

The review of the DIPLAR paperwork and guidance has been completed. The SPS consider that this completes a further 7 recommendations/advisory points. If Gillian takes a different view then they want specific feedback on what they need to do.

Gillian commented that she was aware that the new DIPLAR process had been rolled out and that her view was that it doesn’t address all of the related recommendations/advisory points. In particular, doesn’t feel that advisory points 3, 4 and 6 are fully addressed. Gillian also commented that SPS appear to have taken view that they are not going to appoint a truly independent chair for all DIPLARs, despite this recommendation having been agreed by the Scottish Government.

In relation to recommendation 1.3, Gillian asked what plans the SPS had to make their website more accessible to families, as most people look online as a source of information. Sue Brookes advised that a new website was being delivered that would contain clearer information for families.

Craig Sayers and Eilidh Cunningham provided an update on behalf of the National Prison Care Network (NPrCN).

The Deaths in Prison Custody Toolkit has been signed off by the Oversight Board and circulated to NHS Boards at the end of October. Includes support and training, guidance on improved communication with families, imbedding of trauma informed practices. Network are aware of variations in health board and in July, Chief Executives were briefing on work to implement the Toolkit.

Healthcare Improvement Scotland will be using the Toolkit as part of their inspection process.

Gillian commented that lots of the recommendations were jointly shared between SPS and NHS and agreement early on about who would lead on which. The Toolkit however seems primarily aimed at NHS colleagues and queried to what extent SPS staff can use it.

Eilidh Cunningham commented that lots of the resources contained within the Toolkit at publicly available and that the Toolkit will be hosted on SPS Sharepoint.

In relation to the confirmation of death training, the module went live for healthcare staff on 5th July. The Network captured data from 5 establishments in October which showed 83% completion rate. Some people will do as part of their induction so unlikely to have 100% completion rate. NHS Lothian have committed to have the training completed by end of January 2024 due to resourcing issues.

New MORs guidance that is being developed with advice from the Royal College of Emergency Medicine, has been shared with prison GPs forum and will also be shared with SPS and ambulance service staff for their feedback.

Network are continuing to monitor GeoAmey performance and number of missed appointments. There was discussion around communication from the National Clinical Director that NHS Boards had been requested not to put to the end of waiting lists those who had missed appointments due to actions of GeoAmey.

Network arranged training on FAI that was attended by more than 40 NHS staff. Hope to arrange future sessions.

Gillian queried in respect of recommendation 5.1 whether the Network were confident that families were being involved in SAER.

Andy Shanks provided an update on behalf of COPFS.

In respect of information sharing, there had been positive engagement in the last few months with SPS. Looking to find way of sharing information with families earlier. Engaging with HIS to look at SAERs across country, common themes arising such as provision of information and quality of report. These both impact on what families receive and have a knock on impact on deaths investigation process.

There was a discussion about the importance for families of sharing information and providing answers to questions they have, part of this was providing early access to the outcome of the DIPLAR.

Gillian commented that it was difficult for families to understand why recommendation 3.2 wasn’t yet implemented and organisations haven’t yet agreed what can be shared.

Kerry Knox commented that they still hear inconsistent things from families about what information they are being given and on occasions have to intervene to ensure that family are made aware of the DIPLAR.

Sue Brookes commented that the new DIPLAR paperwork will make it easier to check and audit that families are being spoken to about the DIPLAR.

Matt Paden provided an update on behalf of Police Scotland.

Continuing to develop the MOU on information sharing to support the work of the pilot for the key recommendation. Working closely with COPFS on this.

Chaired the first meeting of the Death in Prison Custody Governance Board in August and the next meeting will take place in January. This is an operational group with representatives from Police, COPFS and SPS. NHS to be invited to next meeting. Group was created as no national structure to act when areas for improvement were identified and to enhance quality of investigations.

Sue Brookes raised a concern about the delays in families being informed by Police about a death and wanted to discuss this further. Suggested that possibly should move to a position where Governors should telephone a family to deliver this news, rather than have a police officer attend to speak to them personally.

Update on implementation of the key recommendation

Cat Dalrymple provided an update on behalf of the Scottish Government.

Thanked everyone for their cooperation and collaboration. Particular thanks to Asha for providing family representation.

First pilot exercise took place over two days in October with an anonymised case. Aware number of teething issues, very much a finding feet exercise. Currently HMIPS are in final stages of drafting report.

Few issues been identified that will feed into the evaluation, such the stage at which some information was made available to the HIIPD investigation team, if process could be seen as independent and resources required. Evaluation process has started. It is recognised it will have limitations and further pilots will be required which will attempt to stick to the process more closely. All organisations will be asked for their feedback.

The evaluation process will try to establish the workability of the new process and if it meets the requirements of the key recommendation. Will then consider if moving to phase 2 of the pilot, which will require Cabinet Secretary approval. Would need to be satisfied thoroughly tested the process with no additional harm.

Cat Dalrymple thanked everyone for being involved and for approaching with an open mind.

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

Gillian Imery provided an update on this workstream.

Group have struggled to pin down the intention of the framework. Understanding data is a big part of that. SPS proactively engaged and sought to be part of the group.

First analytical report was published at the end of August. Hoping it will be the first in a series. It was a fairly basic product that looked at deaths between 2021 and 2022 using data available on the SPS website. The next stage will be a report led by National Records Scotland and Justice Analytical Services and will include comparison trends with the general population.

Nicola McAndrew provided an update on ongoing improvement work in respect of prisoner healthcare.

A Strategic Leadership Group (SLG) was established earlier in the year, was due to last 6 months but will be for slightly longer. Purpose was to bring together leaders in health and justice systems to remove barriers to healthcare in prisons. Acknowledged won’t be solution to all problems.

Clinical IT project has been funded. Well known this causes day to day issues and clinicians struggling with current system. This is a long term piece of work.

Three task and finish groups were established that report to the SLG, each with a different focus.

  1. Rules and regimes – considering how current prison rules and regimes impact on provision of healthcare.
  2. Target operating model – considered improvements to the system to support better delivery of healthcare. Next phase is the NPrCN looking at how it could be implemented.
  3. Raising awareness – led by SG. Every health board identified a prison healthcare lead for prisons, met at end of October. Discussed importance of understanding health needs and key priorities for health boards. Mechanism emerging to have a place to have discussions about things relating to prisoner healthcare that need implemented across boards. 

Update from family reference group

Unfortunately neither Asha or Stewart could attend the meeting today. Asha did kindly provide some comments by email.

Asha commented that she and the family reference group would like to acknowledge Gillian's attendance at the criminal justice committee and wanted to thank Gill on how accurately she talked about the progress of the recommendation and the families frustrations. The families wanted to comment that consistency is key when working with families and feel disappointed that Gill’s time as external chair is coming to an end. They feel Gill’s independent role helps hold organisations to account from the side of the families. 

Asha provided some feedback at the input from NHS at the last family reference group meeting. Expressed some frustrations about a lack of trust for families which is influenced by the disaggregated structure of the NHS and individual health boards. Important that the NHS ensure there is a direct point of contact for families.

The pilot of the key recommendation has started. Asha commented she found the pilot exercise interesting and highlighted how easily mistakes happen. Raised concerns about the independent of the investigation. Asha commented she thought this had potential to improve things for families.

Families still feel as the 2 year mark is approaching of the Independent Review being published that they are disappointed by the pace of progress. Asha commented that SPS have been great at involving families and taking on board their comments and wanted to thank them for that.

Kerry Knox advised the group that a memorial service for families affected by a death in custody had taken place in Glasgow at the weekend attended by 14 family members. Event was a success and they hope to make it an annual event.

Any other business

Cat Dalrymple thanked Gillian for leading the group through the last two years of scrutiny, challenge and being a critical friend.

Responsibility will fall to the Scottish Government to ensure oversight and accountability so that all of the organisations don’t lose sight of what they are trying to achieve. Need to consider the most appropriate mechanism.

Key recommendation working group will be maintained until a decision has been made about what can be delivered. Would also like family reference group to be maintained.

Gillian confirmed when the family reference group next meets she would be happy to discuss with them their thoughts on whether they wished the family reference group to continue.

Gillian closed the meeting by thanking everyone for attending the meeting and providing updates on their ongoing work.

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