Fatal Accident Inquiries: Ministerial Accountability Board minutes - December 2025

Attendees and apologies

Board members

• Angela Constance MSP, Cabinet Secretary for Justice and Home Affairs
• Sam Gluckstein, Head of the UK National Preventive Mechanism
• Sarah Armstrong, Professor of Criminology at University of Glasgow, SCCJR researcher and co-author of ‘Nothing to See Here’
• Phil Wheatley CB, British prison officer, formerly the Director General of the National Offender Management Service and before that, the Director General of HM Prison Service
• Professor Nancy Loucks OBE, Chief Executive of Families Outside and co-chair of the Independent Review into Deaths in Prison Custody, Chair to the DiPC Family Reference Group
• Nicky Brown, Head of Service at PDSO (Public Defence Solicitors Office)
• Dr Sarah Couper, Consultant in Public Health Medicine (lead consultant for mental health), Public Health Scotland

Action owners 

• Cat Dalrymple, Scottish Government (SG)
• Denise Swanson, Scottish Government (SG)
• Teresa Medhurst, Scottish Prison Service (SPS)
• Programme Executive, Scottish Prison Service (SPS)
• Prison Healthcare Lead, NHS Forth Valley (FVHB)

Additional attendees

• Paul McKinlay, Scottish Courts and Tribunals Service (SCTS)
• Localities Manager, Falkirk Council, Social Work
• Justice Social Work Policy and Practice Lead, Social Work Scotland

Secretariat 

• Scottish Government officials

Items and actions

Welcome and opening remarks

The Cabinet Secretary welcomed members and outlined the purpose of the meeting: to address the critical issue of information sharing across agencies.

She reflected on recent cases that exposed significant gaps in risk assessment and communication, noting systemic weaknesses in how suicide risk information is gathered, stored, and shared across the justice system.

The Cabinet Secretary drew attention to Sheriff Collins’ recommendations (7, 8, and 11–13), emphasising the need to strengthen communication, responsiveness, and accountability in managing suicide risk for young people in custody.

She set out the objectives for the session: to review progress on the recommendations, identify current vulnerabilities in information sharing processes, and reaffirm a shared commitment to a coordinated approach to suicide risk management.

Action owners updates

Recommendation 7: Put in place a system to ensure that all written information and documentation available to a court at time of remanding a young person is passed to SPS with that young person on admission.

The Cabinet Secretary invited Scottish Government (SG) to provide an update on progress with Recommendation 7, which focuses on strengthening information sharing between the courts and Scottish Prison Service (SPS).

SG outlined their engagement with stakeholders across justice agencies, which highlighted the need to improve both the gathering of key information and the consistency of how it is shared.

A visit to Glasgow Sheriff Court, hosted by the Scottish Courts and Tribunals Service (SCTS), allowed SG and SPS colleagues to observe the information available to sheriffs and discuss current processes in that region.

A subsequent visit to HMP Edinburgh helped clarify the admission process for this prison, initial assessments and the operation of Talk to Me, providing a clearer understanding of what information is required at the point of entry into custody.

SG reported early progress, noting anecdotal confirmation that information gathered by justice social workers to support sheriffs’ sentencing decisions is now shared with SPS when a custodial sentence or remand is imposed. Previously, pre-conviction bail suitability reports were not routinely passed to SPS, but these are now included within court papers.

SG emphasised that ensuring compliance and consistency across all courts and SPS establishments will be essential to sustaining improvements.

SG noted continuing variation in information sharing, with reliance on paper-based documentation and inconsistencies in what accompanies individuals on admission to custody.

SG set out proposed medium and long term improvements which could enhance information sharing between courts and prisons, though acknowledged full impacting and further discussions are required before agreeing next steps.

SG summarised that progress has been made, but further action is required to strengthen information flows across justice partners, embed compliance, and improve wider multi-agency information sharing aligned with Recommendation 8.

SG concluded by underscoring the importance of ensuring all agencies are clear about the processes in place and apply them consistently.

SG closed by inviting MAB members to share views on implementing and assuring compliance, adequacy of medium-term improvements, a possible wider review of information sharing, and links to other FAI work.

• Members acknowledged that there was a need for assurance activity to be undertaken to ensure that information is being passed between the courts and SPS as expected/understood in practice.

Recommendation 8: Introduce a secure electronic portal for suicide risk information to be shared and accessible by prison staff.

The Cabinet Secretary invited SPS to provide an update on Recommendation 8, which proposes creating a secure portal for social work, healthcare, and third-sector partners to share suicide-risk.

SPS noted that implementation requires substantial infrastructure changes and agreement across partner agencies.

The ‘Bail and Release from Custody (Scotland) Act 2023’ and the ‘Prisoners (Early Release) (Scotland) Act 2025’ require significant updates and testing to SPS IT systems, which is currently underway.

SPS confirmed their commitment to progressing the digital portal to implement Recommendation 8, with initial scoping work planned to start in 2026. Current digital transformation projects, including modernising information management and upgrading systems, are laying the groundwork to enable future delivery.

Health & justice interaction (recommendations 11–13)

The Cabinet Secretary invited NHS Forth Valley (FVHB) to provide an update on progress with Recommendations 11, 12 and 13, which focus on information sharing, training and mental health referral practices between Health and Justice agencies.

FVHB reported that information sharing and coordination with SPS have improved since 2018. This has been supported by shared administrative arrangements. Staff complete mandatory training in suicide prevention, information governance and professional boundaries.

FVHB noted that recruitment and retention of the workforce has improved, but they still require further resource. The requirement to assess risk for the new admission 72-hour observation period has significantly increased workload for current staff and is straining Forth Valley NHS mental health resource capacity.

Following the FVHB presentation, the Cabinet Secretary asked if attendees would like to add anything regarding information-sharing updates. SPS reported that more information is now being received from the courts. The focus on information sharing has helped identify areas for improvement, particularly with the admissions process as not all information is accessed in a timely manner due to the large volumes of it. SPS noted that improvements are ongoing, particularly with the overarching sharing of information with Local Authorities.

Discussion with MAB members

One member asked FVHB about the involvement of families in case conferences. FVHB explained that prisoners can choose whether their families are included in this process.

FVHB highlighted that challenges remain due to paper-based systems, as forms can be lost at various stages. Scanned mandates are retained, however, forms can be misplaced when shared between different organisations.

Attendees discussed opportunities to strengthen information sharing:

• Reducing reliance on paper and moving toward digital systems was highlighted.
• Even with digital systems, information often remains fragmented, and systems do not communicate with each other. FVHB noted that, in line with their practice, patients are entitled to decide what information is shared, including whether family members are involved in case conferences.
• The quality and prioritisation of shared information is important, enabling prison staff to access the most relevant details without being overwhelmed by excessive paperwork.
• Members noted the importance of ensuring that short term reforms and improvements are taken forward to improve the paper forms currently in use prior to the implementation of new digital systems.

Admission processes were identified as a pivotal point for timely decision making:

• Attendees highlighted the complexity of case management during admission, noting that multiple types of information (health, prescriptions, and admission details) must be considered. It was emphasised that processes need to support timely access to essential information without overwhelming staff with excessive material.
• Practical challenges were discussed, including late arrivals, differing sentence types, and complex prisoner histories, all of which can reduce the time available for reviewing documentation.
• One member noted that the admission process often continues over several days and can feel more like a settling-in period than a single admission event. The potential value of using more peer support was raised as a possible way to support new arrivals to settle in, freeing up staff time to do more structured and efficient assessments of information.
• It was acknowledged that many individuals entering custody present with additional needs. Justice social work noted that some local whole system approaches have demonstrated positive results, and that adopting such practices more widely could strengthen admission processes across the estate.
• Not all improvements require substantial resources - the use of peer mentors and third-sector support was highlighted as a way to reduce pressure and enhance early custody experiences particularly during admission.
• Over-emphasis on removing paperwork should not overshadow the broader objective of helping individuals feel safe and supported during their first nights in custody.
• The current administrative system was noted as insufficiently structured. One member suggested that slowing down the process to prioritise quality over volume, and adopting a softer, more supportive approach, could improve admissions. Focus should be on creating a culture change that makes the process safer, more manageable, and centred on individual needs.

Information sharing from courts was discussed:

• One attendee highlighted that reports and forms do not always reach prisons routinely from court, and some information may be missed. Verbal reports and vulnerable-person templates need to reach the appropriate staff at the right time. It is also hard to know whether documents are missing or if they were not required by the court as there is no way to record this currently.
• Justice social work reports contain valuable risk information, but processes for transferring these to custody remain inconsistent. Monitoring of electronic portals and ensuring the right staff access the information were identified as key to sustaining improvements.
• One member said that certain aspects of legislation, especially regarding mental health, combined with differences between rural and urban courts, can create inconsistent approaches.
• One member expressed their experience of significant information sharing gaps within court processes. In many courts - particularly rural ones - key reports may not be available due to limited access to social work or other professionals. In their experience, sheriffs are expected to consider fitness for custody, but only a very small proportion of assessments are arranged directly by the court due to the nature of the mental health legislation and the criteria for eligibility. In most cases, any psychiatric or related assessments are commissioned by defence agents, and the Crown is not required to notify prisons about whether such assessments have been undertaken. As a result, prisons will only receive this information if they specifically ask for it. Defence agents often request additional time to obtain reports, which can include valuable risk-related information. Sheriffs may reference these reports in court, but there is no clear process to ensure they are shared with prisons. It was noted that current mental health pathways do not give Sheriffs a mechanism to direct this information onward, meaning that in practice, responsibility for producing and communicating it largely falls to defence.
• One member proposed commissioning mental health specialists to ensure prisons receive timely and relevant assessments to inform risk management and placement decisions.

One member noted that concerns are not limited to mental health; physical health issues may also require attention, and the Crown has a role in directing individuals to the most appropriate facility if they are not well enough to plead in court.

Default procedures for late arrivals (individuals entering custody later in the day or at night) typically involve seeing individuals the following day; however, for those with significant risk concerns, such as suicide risk, a suggestion is that sheriffs should ensure relevant reports are requested and reviewed.

FVHB highlighted a recurring challenge: individuals may be remanded in custody before their information has been fully shared or assessed, creating a “spiral” where they enter custody without a complete understanding of their needs.

• Participants discussed the sharing of health and prescription information, and noted people can be remanded in custody without a reliable source of information about their current medications. There is also difficulty in obtaining reliable information on individual drug use history. Justice social work reports include information on drug dependencies where applicable but social work reports are not always issued or requested by the court, and therefore not always shared with the prison. FVHB highlighted the importance of reliable patient pathway information from time of arrest until they arrive in prison to enable treatment decision making that would support drug withdrawal for example, and keep them well and safe through their first night.

One member sought clarification on the terminology used to categorise urgency in patient care. Concerns were raised about how labels such as “urgent” and “non-urgent” are applied, and what criteria underpin these decisions. FVHB explained that “urgent” refers to individuals presenting in crisis who require immediate attention, while “non-urgent” patients are placed on a routine waiting list, which in some instances can currently extend up to two months. FVHB also noted the risk that quieter or less vocal individuals may not be identified promptly and highlighted ongoing resourcing challenges linked to the increase in workload following the 72 hour assessment process.

The Cabinet Secretary emphasised that prisons do not operate as hospital facilities; systems are legally and operationally distinct, and placing individuals in the wrong system can negatively impact their journey and preparation for return to the community.

SG summarised that medium to long-term improvements are needed in court processes, information sharing, and admission procedures, particularly for young people, and highlighted resource constraints and the need to balance quick improvements with properly implemented changes.

SG will follow up with meeting attendees who provided input relevant to their work to consolidate learning from court processes and information availability, and to revisit opportunities for improvement.

SPS suggested that case summaries could support all partners involved in improving the quality of information sharing. Justice social work noted that this could be facilitated by court social workers, but highlighted potential resourcing constraints.

Progress report review

The Cabinet Secretary noted that SPS will share an embargoed copy of the ‘Talk to Me’ (TTM) report with members ahead of publication and suggested it could be added to the agenda for the February meeting.

The Cabinet Secretary also highlighted the deep-dive session on the progress report, which members had undertaken with the Secretariat ahead of the meeting, and invited any additional questions or comments.

The Cabinet Secretary noted members had received a copy of the National Oversight Mechanism (NOM) position paper and asked SG if there were any additional updates. SG reported that there were no significant updates but expressed eagerness to continue discussions on the interim model during the February meeting and to engage with partners on next steps. One member noted that the Family Reference Group are keen to be consulted on the NOM and the Family Advocacy work underway. SG confirmed that the group would have the opportunity to do so.

MAB Members reflections on what they have heard on Information Sharing

Action owners and additional attendees left the meeting at this point and the discussion continued with MAB members and the Cabinet Secretary to reflect on the updates provided. 

Meeting closed.

Post-meeting agreement

Following the conclusion of the meeting, members agreed on the following position statement:

Board members reflected a collective view that the current system is under significant pressure and is not structured in a way that reliably shares information about risk and support for vulnerable individuals being admitted into custody. Issues relating to information sharing have persisted in the justice system over many years.

Members observed that certain features of the legislative framework, particularly in relation to mental health, combined with differing processes between rural and urban courts, can unintentionally create system pressures and inconsistent approaches. Remand admissions, which often occur at unpredictable times, may result in individuals entering custody before key information has been received and disclosed.

Members felt encouraged that shifts are happening within SPS but that major leadership and commitment to change is required to embed information sharing capability across the whole system. It was positively noted that key stakeholders are confident that documents held by the courts are being shared routinely with HMP and YOI Polmont. However, the volume of information going into a national facility has now increased, which is an added challenge. The members also reflected that the 72-hour observation period for all custody admissions relating to young people adds considerable operational pressure in the system, placing strain on specialist capacity within the Forth Valley NHS mental health team.

Board members agreed that significant digital transformation is essential. Ongoing issues with paper flow, quality and visibility of key pieces of information present continuing risks to being able to fully understand the needs of those who are admitted into custody.

While the long-term digital system is in development, members expressed urgency around progressing interim measures to bridge gaps until the expected introduction of a digital solution in 2027. The Board is aligned in its expectation from action owners that immediate stabilising measures for example, clearer understanding about who needs what when, strengthened assurance processes between partners sharing information, formalised input from defence agents and better-supported staff, must progress alongside longer-term digital and structural change. For example, members highlighted the value of engaging with Public Defence Solicitors’ Office (PDSO) to clarify the role of defence solicitors and establish effective pathways for information sharing. They also emphasised that concise, well-structured case summaries, potentially supported by digital tools, will be critical to managing and controlling the volume of information.

The Board recognises that improvements are not solely procedural or necessarily involve vast amounts of additional resource; cultural factors and softer adjustments also shape outcomes. Members noted that process failures early in custody create downstream risk and supported a shift toward a more holistic, supportive approach to early custody. It was noted that an over-emphasis on removing physical items can overshadow the wider aim of helping individuals feel that their first nights are manageable and safe. Use of peer mentors and third sector at this time could ease pressure on prison staff. Members stressed that admissions processes must allow prison reception staff the time to review papers and interpret information to make appropriate risk assessments.

In summary, short-term improvements should be pursued without delay, and continuing these efforts alongside longer-term initiatives will progressively strengthen confidence that the actions taken are tangibly enhancing the safety of those within the custodial environment.

This reflects the collective position reached after discussion and closure of the meeting.