Deaths in Prison Custody Action Group minutes: September 2022

Minutes from the meeting of the group on 27 September 2022.

Attendees and apologies

  • Gillian Imery, External Chair, Oversight of Recommendations of Review into Response to Deaths in Prison Custody
  • Asha Anderson, representative for families bereaved by a death in prison custody
  • Stewart Taylor, representative for families bereaved by a death in prison custody
  • Cat Dalrymple, Deputy Director, Community Justice, SG
  • Suzy Calder, Interim Head of Health, SPS
  • Sue Brookes, Director of Strategy and Stakeholder Engagement, SPS
  • Sheena Orr, Prison Chaplain, SPS
  • Catherine Haley, 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
  • Stephanie Blair, Principal Procurator Fiscal Depute, COPFS
  • Quentin Fisher, Team Leader, Prisons and Parole Unit, Community Justice, SG
  • Laura Begg, Community Justice, SG


  • Nicola McAndrew, Team Leader, Prison Healthcare, SG

Items and actions

Welcome and introductions

Gillian Imery welcomed everyone to the second meeting of the DiPCAG. Asha Anderson was introduced to the group and thanked for attending as a representative of families bereaved by the death of a family member in prison. It was explained that Asha was also a member of the family advisory group who helped inform the work of the Independent Review.

Minutes of last meeting, terms of reference and update on actions

Gillian Imery advised the group that any comments received had been incorporated into the final version of the minutes of the last meeting. A draft of the Terms of Reference for the DiPCAG had also been circulated and any comments incorporated.

Update on other actions from the initial meeting to be covered in other agenda items. 

High level work plan

Gillian Imery advised the group that the high level work plan is an ambitious vision of how she saw the recommendations of the Independent Review being implemented. Tried to capture on one page what was felt to be realistically achievable in reasonable timescales in broad themes. Actions had been categorised into four broad themes - leadership and governance, workforce and training, design and delivery of services and quality improvement. Sets out the overall vision of the work of the group and what seeking to achieve. It should be noted that already behind with progress and not achieving some of the early progress actions.

Gillian Imery acknowledged that there may be other ongoing work in respect of improvements to practice but this high level work plan relates solely to the implementation of the recommendations of the Independent Review.

Sue Brookes commented that SPS would like more time to consider the plan. They wanted it to include flexibility with ability to shift timescales. Felt there should be recognition of the very difficult fiscal context which was having an impact on staff recruitment and retention.

Update on progress to implement recommendations

Gillian Imery thanked the group for providing updates and for the ongoing work being done to implement recommendations.

Suzy Calder and Sue Brookes provided an update on behalf of the SPS. It was explained that the SPS Internal Tasking Group was now up and running. National Prison Care Network were a member of the group to help ensure partnership working between the SPS and NHS. A DIPLAR review audit group had also been established and the Terms of Reference agreed that day. There was a broad spectrum of representatives on that group including NHS, SPS, HIS, NES and Union Representation.

SPS had shared a number of documents that the family reference group were going to provide feedback on – electronic concern forms, family support booklet and DIPLAR forms. Feedback will be used to continue to work to shape these documents.

There was now 100% coverage of privacy screens in establishments and work ongoing to ensure processes in place to ensure access to them. In respect of ligature cutters, there were some practical difficulties to be overcome and a business case had been submitted. 

Most Governors in Charge (GIC) were now acting as the first point of contact for families, although this may be another senior member of staff such as the duty manager if they were the person onsite.

Gillian Imery queried why not all GIC were acting as the first point of contact for families. Suzy Calder explained that it was someone from the senior management team who was contacting families and there needed to be a conversation about who was best to talk to families. Some feedback that families want to talk to someone who knew their loved one. Suzy Calder also commented that some GIC find it difficult to undertake this role and they need the right support and training.

Suzy Calder explained that the SPS will share the framework in respect of GIC/senior management team being the first point of contact with the family reference group and will use their feedback to test their ideas.

Asha Anderson commented that it was very positive and refreshing to hear that the SPS were willing to engage with families and that families will do what they can to help.

Sue Brookes commented that as conversations developed and feedback was received then some of the recommendations may need to be modified.

An update was also provided on some other work being progressed by the SPS that was relevant to a wider approach to reducing vulnerability. This includes the introduction of Harm Reduction and Inclusion Managers, initially in HMP Shotts and Polmont and then Edinburgh; the roll out of non-pain inducing restraint and greater information sharing between agencies.

Workshops on trauma informed care are being rolled out commencing in November and a sub-group has been set up to review Critical Incident Response.

Nancy Loucks asked whether families were now more involved in the DIPLAR meetings.

Sue Brookes responded that there was no forum for families to attend the DIPLAR meeting but it was being asked at the DIPLAR meeting about any communication with families.

Craig Sayers provided an update to the group on behalf of the NHS. In respect of nurses confirming death had occurred a process had been agreed but there were some difficulties in implementing it due to staffing numbers. Other training options are to be discussed.

Progress is being made on the creation of a single pathway for processes to be followed after a death. Working with the SPS on this document.

In respect of trauma informed training had met with NES and exploring available training and how this can be delivered.

Catherine Haley provided an update on behalf of Healthcare Improvement Scotland (HIS). She advised that HIS were looking towards national improvements. Have launched a standardised programme for the way that adverse events are reported to reach agreement nationally about what circumstances lead to a review happening. The framework will be reviewed that will include input from families/carers.

HIS are involved in quality assurance of prisons and the inspection process. Considering whether anything further should be inspected on. HIS are also feeding into the work of the SPS DIPLAR review group. 

Craig Sayers commented that it was clear there was wide variation across health boards in the way adverse events were managed and it was welcomed that adverse events within a prison setting would fall within a wider pathway.

Stewart Taylor commented that it was really positive that there was more joined up working ongoing between the SPS and NHS.

Katrina Parkes and Stephanie Blair provided an update on behalf of COPFS. A general update was provided on work being done to improve the system of deaths investigations. COPFS are working closely with the SG re improvement, which includes the conduct of FAIs. Looking to identify opportunities to get views from families and how they felt about communication by COPFS. Had received very helpful feedback so far. Considering the creation of a FAI pack to provide more information about the process.

A specialist team has been established that is responsible for the investigation of deaths occurring in legal custody. From an investigation point of view this could help identify trends and patterns occurring.

In respect of recommendation 3.2, the Custody Deaths Unit are working on an information sharing unit agreement with the SPS to establish a Memorandum of Organisation between the two organisations. This will set out what information can be shared and at what stage. Also involved in talks with Police Scotland about the sharing of information.

Nancy Loucks asked how the Custody Deaths Unit would work with the new investigative process. Katrina Parkes advised that COPFS were working with the key recommendation working group to navigate that relationship and that the need for this new specialist unit had been identified before the publication of the Independent Review.

Asha Anderson and Stewart Taylor commented on some aspects of the FAI process they felt could be improved, such as it being made less formal. They also suggested that COPFS could talk to the family reference group to get the benefit of hearing about their experiences.

Matt Paden provided an update on behalf of Police Scotland. The group were advised that Laura Waddell had now moved post and in the meantime whilst her successor was appointed Matt Paden would continue to be involved with this work. Although Police Scotland were not named as owners of any of the recommendations, they were working in background to support them. They had been sharing information on police processes with the key recommendation working group and also briefing the family liaison coordinator on the draft process map.

Update from Scottish Government on key recommendation

Cat Dalrymple provided an update on behalf of the Scottish Government key recommendation working group. Advised the group that whilst they were trying to make progress, needed to be upfront that it was slow. Work at the moment was focusing on trying to define the investigative parameters. Wanted to get the input of families on how best to communicate with them. There are challenges in trying to fit in the new process with current processes and the boundaries of the constitutional position of the Lord Advocate/Police Scotland.

Cat Dalrymple informed the group that she had attending twice at a meeting of the family reference group. Family members had requested to attend meetings of the key recommendation working group and that request had been welcomed by the group. The group had agreed certain parameters for family member attendance on the group.

Felt approaching a stage where have a clearer vision agreed with partners. At this stage, no agreement of what body will take on the role of conducting the independent investigation, felt that is secondary question to getting process right.

Commented that it seems aspirational to have the new process in place within eighteen to twenty four months. Hoping by that time will be at stage of doing a pilot to see if process works in practice.

Update on engagement with families

Gillian Imery expressed her thanks to families who were willing to contribute their own experiences to this work.

Asha Anderson advised the group that there was a general consensus from families that there was frustration that they were not seeing enough progress on the recommendations. Families feel that they are not seeing enough milestones and what the different organisations are working towards.

Asha Anderson commented that the families want to work with everyone represented on the group and give them as much help as possible to make sure the recommendations do take place. Families will be as open as they can be about their experiences and views and would like that in return from organisations.

Gillian Imery acknowledged that all members of the DiPCAG benefited enormously from hearing feedback from families. The group were also reminded of the need to produce deadlines and targets when being asked to provide updates on progress. This would help provide more accountability to families on progress.

Update on the working group progressing recommendations on understanding and preventing deaths in prisons (1.1 and 3.4)

Gillian Imery advised the group that a working group has been established to progress recommendations 1.1 and 3.4 which have a focus on understanding and preventing deaths in prisons. That group has met once and next meeting to take place tomorrow. The group will be co-Chaired by Linda Allan, a bereaved family member and honorary professor at the University of Glasgow. Initial focus of the group has been a mapping exercise to establish ongoing work/strategies that could potentially feed into the creation of a framework on preventing deaths in prisons and to identify gaps.

Update on transparency on progress

Gillian Imery advised the group that to improve transparency a page is being set up on the Scottish Government’s ‘Groups’ page of the website. Once this page is live, will be able to publish minutes from meetings, high level work plan and action plan on that page. Families Outside will potentially help publicise to other family members who may have an interest in progress.

Gillian Imery is next meeting with the Cabinet Secretary on the 3rd November, to provide him with a regular update on progress. Reminder of intention to publish a progress report at the end of November. Group advised they are likely to be asked for further details to populate that report. At the moment, Chair is not going to be able to confirm that any of the recommendations are complete.

Any other business



  • All to consider the high level work plan and provide any comments to Laura Begg by 21 October
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