Fatal Accident Inquiries: Ministerial Accountability Board minutes - February 2026

Attendees and apologies

Board members

• Angela Constance MSP, Cabinet Secretary for Justice and Home Affairs
• 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
• Dr Sarah Couper, Consultant in Public Health Medicine (lead consultant for mental health), Public Health Scotland

Action owners 

• Teresa Medhurst, Scottish Prison Service (SPS)
• Programme Executive, SPS
• James McLellan, Scottish Government (SG)
• Head of Prisons Unit, SG

Additional attendees 

• Sheriff Principal Abercrombie

• Scottish Governement officials supporting the Fatal Accident Inquiry Review.

Secretariat 

• Scottish Government officials

Apologies

• Nicky Brown, Head of Service at PDSO (Public Defence Solicitors Office) 
• Sam Gluckstein, Head of the UK National Preventive Mechanism

Items and actions

Welcome and opening remarks

The Cabinet Secretary welcomed attendees and outlined the thematic focus of the meeting as ‘systemic change’. The agenda covers two major areas of work critical to strengthening accountability and improving safety across the system – the independent review of the Fatal Accident Inquiry (FAI) process, and the establishment of a National Oversight Mechanism (NOM).

Presentation from Sheriff Principal Abercrombie on the independent FAI review

Sheriff Principal Abercrombie provided an overview of the findings and recommendations from his independent review of the FAI process published on 15 January 2026.

Sheriff Principal Abercrombie explained that the recommendations were purposefully intended to be practical and minimise additional resource strain, to enable effective implementation.

Sheriff Principal Abercrombie outlined the three key themes from his review:

• the delays in the FAI process are completely unacceptable. They need to be completed quickly to determine what happened and what can be done to prevent it happening again

• people, in particular bereaved family members, should be treated far better throughout the FAI process

• there needs to be significant improvements to action and accountability around FAI findings and recommendations, including a mechanism for follow-up to ensure they are acted upon in a meaningful way

Sheriff Principal Abercrombie emphasised the importance of separating out independent investigations into deaths from the implementation of recommendations. He also asserted that there should be a system in place for tracking learnings holistically across FAIs, as this would help to inform improvement action and resource allocation.

Sheriff Principal Abercrombie also stated the importance of Ministerial involvement in this work. He recommended that this would be particularly useful in relation to decision-making and prioritisation for implementing recommendations from FAIs. This should enable informed decisions about resource and budget allocation in a way which supports longer-term and bigger-picture reforms, as opposed to individual areas being considered in silo. Having Ministerial direction around this work should also enhance accountability and transparency by providing clear rationale underpinning decisions (for example why particular reforms are prioritised over others, and why particular recommendations may not be feasible to implement).

The Cabinet Secretary reflected that the implementation of recommendations ought to be considered collectively and as part of a holistic direction of travel.

Members reflected on the review findings and agreed that the timescales associated with the FAI process are wholly unacceptable. They also agreed that there is a fundamental need for greater accountability and meaningful action being taken around the findings and recommendations following a death in custody.

Members also discussed how the FAI process could be improved going forward.

• members discussed required improvements in the actual investigation element of the process following a death in custody. In their view, these do not always focus on the right things and therefore may result in learnings related to the physical nature of the deaths as opposed to preventing the underlying causes (e.g. focussing on particular ligature points as opposed to factors which contributed to feelings of hopelessness and despair)

• members discussed Sheriff Principal Abercrombie’s recommendation that a specialist dedicated unit within the Police should be responsible for conducting investigations as part of the FAI process. Members agreed this could enable quicker investigations, however they stressed the importance of the unit having enhanced expertise and independence, with specialist training on prison custody deaths for it to be able to investigate FAIs sufficiently. One member suggested an alternative approach where a fully independent body, akin to the Ombudsman for England and Wales, could be established and take on this responsibility in Scotland. This was considered as part of the review, but would likely have significant cost implications and may require legislation which may limit its feasibility and cause delays in set up

• sheriff Principal Abercrombie recommended that any new approach to FAIs should be subject to a full and objective evaluation after a few years to determine whether it is working as intended, or whether a new approach should be developed

• one member emphasised the need for investigations to consider Human Rights Article 2 which protects the right to life, specifically systemic issues which may have contributed to deaths

• members acknowledged the collective action which will be required from various stakeholders to deliver the recommendations from the review and achieve the desired impacts. Members concurred that a collective culture change is required to focus investigations on what went wrong and how it can be prevented from happening again, as opposed to an adversarial defensive position from those involved. Clear direction from Ministerial level will be pivotal in driving this cultural change

• members discussed the Public Office (Accountability) Bill, known as the ‘Hillsborough Law’ and how this links in with ‘duty of candour’ in relation to deaths in custody to enhance transparency and openness when things go wrong

Update on the establishment of the National Oversight Mechanism

Scottish Government officials provided an update on the ongoing work to establish the NOM and invited support and challenge from members on the proposed plans.

SG officials outlined the principles and objectives to designing the NOM: to build something which is credible and durable, which is grounded in robust data and evidence, and which strengthens families’ confidence in the actions that will be taken to prevent further deaths.

SG officials explained the intention to deliver the NOM initially through a ‘test of change’ model within prison custody settings. This approach will allow earlier implementation and quicker realisation of benefits, rather than delaying progress pending legislative changes required for longer-term rollout across wider custodial settings. An existing independent body has been identified and agreed to deliver this ‘test of change’ model.

SG officials outlined the proposed scope for the initial phase of the NOM. This will include the tracking of relevant information on deaths in custody; monitoring the implementation of accepted recommendations arising from FAIs; undertaking thematic analysis to support systemic learning; publishing independent reports; and engaging with families in a trauma-informed manner. The NOM is not intended to replace or duplicate existing processes, including FAIs and the publication of official statistics.

Additionally, SG officials will strengthen governance to provide additional assurances around this work and inform longer-term plans, such as the consideration of additional powers or legislative requirements which may be required to strengthen the NOM’s effectiveness and remit.

Members reflected on the proposed approach and sought further detail on the types of information that would be tracked by the NOM. SG officials explained that the intention is to capture information that contributes to a broader understanding of deaths in custody and welcomed suggestions on particular data that would be valuable to include. Members suggested wider information about the individual’s experience in custody could be helpful, including when they last had family visitation prior to their death, and any prescription medications they were on at the time of death. Information about the individual’s circumstances such as the length and type of sentence could also be useful. MAB members noted these were examples of the types of data that may be of interest and there may be many other data items worth analysing. Looking across a wide range of data could help to enhance understanding of how things link together and inform learning about how to reduce risks in future.

One member suggested it could be helpful for the NOM’s scope to include an element of scrutiny to the investigations following death to identify common themes and wider contributory factors which could support learning to prevent future deaths.

Members queried whether the same independent body would retain NOM responsibilities in the longer term for wider state settings, to which SG officials assured that there would be an independent evaluation of the ‘test of change’ model which would then inform longer-term plans.

Progress report review

The Cabinet Secretary welcomed comments and questions from members about progress of any of the recommendations and commitments.

Members discussed the independent review of ‘Talk to Me’, specifically the findings from Professor Towl’s published report, and queried how SPS could deliver the required culture change amongst its workforce to improve the approach to suicide prevention in prisons.

• SPS officials acknowledged the challenges associated with this, particularly in the context of ongoing resourcing pressures. They highlighted the importance of staff being given sufficient time and capacity to fully understand the new process and the expectations on them. SPS officials described planned work across the various FAI workstreams to agree pragmatic approaches for implementing new processes in an integrated manner. Work is also being progressed around communications and senior leadership engagement to support staff messaging. This is intended to enable and support staff and, in doing so, help drive cultural change

• members queried how the work would translate across the SPS estate, given that the FAI is primarily focussed on young people and HMP & YOI Polmont. SPS officials provided assurances that the ambition is to realise these reforms across all prisons. There are unique challenges in individual prisons which will need to be taken into consideration, as will populations make ups (for example, HMP and YOI Polmont has three distinct populations including young people, adult males and adult females)

Members queried specific timescales for the development and implementation of the new suicide prevention approach. SPS officials stated specific timescales are still being determined and work is ongoing to link with reforms to the Management of Offenders at Risk from Any Substance (MORS) policy.

MAB reflections

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 close

Post-meeting agreement

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

Members noted the content of the FAI review and valued hearing Sheriff Abercrombie’s contributions. MAB members concurred with the findings of the review and welcomed the pragmatic nature of the recommendations. There is clear consensus that the timescales associated with the FAI process are wholly unacceptable. There is also a fundamental need for greater accountability and meaningful action being taken around the findings and recommendations following a death in custody. There is agreement that a collective culture change is required to focus investigations on what went wrong and how it can be prevented from happening again, as opposed to an adversarial defensive position from those involved. There is support for the recommendation around a specialist unit within the Police taking on responsibility for the work and for this be objectively evaluated in 3 to 4 years' time to determine whether it is working as intended, or whether a different approach may be required such as legislation to create an independent body. It is also imperative that investigations consider systemic issues which may have contributed to a death in accordance with article 2 of the Human Rights Act.

After considering the NOM proposals, members agreed that they are supportive of the proposed approach to deliver an initial ‘test of change’ model. This initial phase will be delivered by an existing independent body and involve deaths in prison custody. There should then be an independent evaluation completed which will inform longer-term plans. The ambition must still be to widen the scope of the NOM to cover all deaths in state custody. Having a centralised tool for tracking information related to deaths in custody is welcomed as an enabler of objective and more holistic learning to prevent deaths in future. MAB members agree the data required may need to be built up over time, but that a wide range of data may be required to know what would be useful. MAB members caution that the NOM should not be a passive information gathering system but a mechanism that provides real oversight. Article 2 of the Human Rights Act should be reflected in the model for the NOM.

MAB members and the Cabinet Secretary also agreed that the recommendations from the Sarah Jane Riley FAI will not be folded into the scope of the MAB. This is primarily due to the limited remaining time of the board, meaning there will not be sufficient time or opportunities to meaningfully scrutinise progress. The Terms of Reference will not be revised, and the commission process will not obtain progress updates against these specific recommendations. However, there are broader systemic themes in this FAI which align with those of the Katie, William and Jack FAIs. These will be considered and addressed in the MAB Final Report as part of a section where the further progress needs to be made. This will include the broader issue of progress on mental health and wellbeing support for vulnerable individuals in custody and consideration of how people in custody can be supported to feel hopeful about the future.

In summary, members supported the direction of travel across the FAI review and the NOM, while emphasising the need for culture change, strengthened accountability, and consistent system‑wide learning to improve safety and prevent future deaths in custody.