Fatal Accident Inquiries: Ministerial Accountability Board minutes - June 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

Apologies 

• None

Secretariat 

• Scottish Government officials

Items and actions

Welcome and opening remarks

The Cabinet Secretary welcomed members and thanked them for their agreement to join the Ministerial Accountability Board (MAB).

The Cabinet Secretary explained the purpose of the MAB – to provide a single point of coordination, monitoring and accountability for implementing a comprehensive package of reforms in response to the Fatal Accident Inquiry into the tragic deaths of Katie Allan and William Lindsay (or Brown) at HMPYOI Polmont.

The Cabinet Secretary stated her commitment to drive reform across the Scottish Prison Service, NHS, and other partners. 

The Cabinet Secretary explained the MAB’s role is to oversee the delivery of these actions across stakeholders, ensuring progress is timely, effective, and accountable. It will model collaborative leadership, working to build trust in the system and provide both a support and challenge function to stakeholders to drive the effective delivery of recommendations.

The Cabinet Secretary emphasised the need for open and frank discussion, and the importance of the MAB being a safe place to offer views, respectively challenge and scrutinise.  

Board member introductions

Cabinet Secretary initiated a round table of introductions. Members in turn introduced themselves, provided a brief background of relevant experience and knowledge, and stated their key motivation for joining the MAB.

Members were asked to declare potential conflicts of interest, noted by the secretariat:

• Sam Gluckstein - Trustee for JustRight Scotland
• Phil Wheatley CB - Expert witness for FAIs, 2 ongoing in Scotland but none relevant to the key focus of this Board
• Sarah Armstrong - in a personal capacity supports a small number of families bereaved by a custodial death
• Professor Nancy Loucks OBE - sits on group for Family Advocacy and chairs Family Reference Group

The Oversight and Implementation Unit within the Scottish Government introduced themselves and confirmed their role as secretariat to the MAB.

Terms of reference

Cabinet Secretary directed members’ attention to the draft Terms of Reference (ToR) which were shared in advance for consideration.

Cabinet Secretary explained that the ToR sets out the role, scope and responsibilities of the MAB. It is flexible in that additional recommendations from future Fatal Accident Inquiries may be included at the MAB’s discretion.

Members were asked for any comments or proposed changes to the ToR.

Members discussed broadening the scope of the MAB to cover more settings of detention such as police custody and migration detention, a wider range of self inflicted deaths and other preventable deaths (such as drug related). Cabinet Secretary discussed that whilst the FAI in question was specifically around young people and suicide prevention, this work needed to be the catalyst for broader change within prison.

Members therefore agreed that the primary focus of the MAB is on the recommendations from the Fatal Accident Inquiry into the deaths of Katie Allan and William Lindsay (or Brown); as well as the additional commitments made by the Cabinet Secretary in her statements to Parliament in response to this determination. It was noted that the findings of the determination were also relevant to the Board’s work.

Members agreed the draft TORs should be amended to make explicit the focus is the prison custodial environment alone.

Members agreed that this work should act as a catalyst for change for wider policy and operational reforms in relation to all deaths in custody. 

Members agreed that in addition to its core scope, the MAB may also facilitate discussions and action in relation to wider reform and changes relevant to broader deaths in custody policy.

• action: secretariat to revise ToR and circulate to members for approval

Progress report

Cabinet Secretary directed members attention to the Progress Report paper which was circulated in advance of the MAB.

Cabinet Secretary explained that the purpose is to provide an initial overview of progress across the recommendations and commitments. It sets out the overall position of progress as well as a breakdown at individual recommendation/commitment level. This includes a ‘RAG’ rating to visually categorise delivery confidence and draw attention to areas which are at greatest risk of not being completed as intended. This information has been collated via a self-assessment process with Action Owners, with key information, risks and mitigations included. 

Members emphasised their desire for the MAB to have a strong scrutiny role. There was consensus that actions recorded as ‘completed’ by Action Owners should not necessarily be taken at face value, and that the Board should seek assurance that the relevant actions have been completed sufficiently. This assurance might take the form of submitted evidence, site visits and board attendance from Action Owners and other relevant stakeholders. 

Members also expressed interest in the outcomes of the action taken, whether they were having the desired impacts and instigating appropriate changes in culture, as opposed to simply putting a policy into place. 

Members discussed Recommendation 9 as an example (SPS should provide a dedicated 24 hour telephone number by which family members can call into Polmont in order to notify a concern relevant to suicide risk which they may have in relation to a prisoner.) This recommendation has been reported as completed by the Action Owner (SPS) due to the fact that a phone line is now in operation across all prisons in Scotland. However, members raised some negative feedback received from family members who have used the phone line. 

A member shared feedback from a direct test they conducted on the phone lines recently, noting that the experience may be inconsistent across different estates, the automated options were not particularly user-friendly and that the guidance on the SPS website could more clearly explain the type of concerns which should be raised through the process. 

An audit on the effectiveness of the phone line was suggested as a helpful form of additional assurance that it is having the desired outcomes.

Members discussed information sharing, specifically process gaps in the way in which other individuals can formally report concerns about suicidal thoughts and intent. Defence Agents, who are often the first people to engage with individuals immediately before their incarceration, currently have no formal process in place to communicate such concerns, with current practice reliant on verbal relays of information, and the concern line apparently limited to use by family members.

A member noted that in general in Scotland, policies are of a high standard however the implementation of the policies is poor. There is a divergence between policy and practice and more work is required to assure the utility, consistent practice and effectiveness of these policies in practice.

Members discussed the possibility of engaging in site visits to Polmont, or other prison estates, to see the progress in practice. 

Members agreed that they should be responsible for agreeing the RAG rating and not publish ahead of that agreement.  More evidence was needed from action owners, than the current progress report contained.

Members commented that the data relating to deaths in custody on Scotland is poor. There are challenges with the reliability, completeness and limited nature of existing data.  There are no systems for collecting prisoner suicides within one database to inform risk assessments.

One member commented that there should be an internal form of audit as is the case currently for HMP Addiewell. 

Cabinet Secretary agreed that the data on deaths in custody needs to be enhanced to facilitate research and interrogation to drive informed improvements.

Secretariat informed members that one of the MAB’s tracked commitments is around His Majesty's Inspectorate of Prisons for Scotland (HMIPS) completing an independent inspection to review whether the actions taken are meeting the required outcome. This work is intended to complement the role of the MAB and is due to take place over summer, with an update scheduled to the September MAB.

• action: secretariat to consider how to assure and evidence completion of recommendations by Action Owners and factor this into MAB reporting
• action: secretariat to relay feedback to SPS about the phone line to report concerns (Recommendation 9) and explore options for reviewing its effectiveness
• action: secretariat to ensure information sharing gap identified in relation to Defence Agents formally reporting suicide concerns, is incorporated into wider information sharing work
• action: MAB to consider how to enhance data within Scotland on deaths in custody to facilitate research and interrogation; and identify what data is needed
• action: secretariat to explore pragmatics of facilitating site visits to prisons by MAB members

Ways of working

Cabinet Secretary drew members’ attention to the Ways of Working paper which was circulated in advance of the MAB. 

Cabinet Secretary outlined the proposed arrangements for how the MAB would operate in practice and what the reporting mechanisms would be.

Members agreed that in the interests of transparency, information about the MAB should be published on the Scottish Government website. This will include the ToR (pending refinement and approval by members) and Minutes following each MAB meeting.

Members also agreed that an update on progress should be published in due course, once members have endorsed the content and are confident about the status of the recommendations/commitments

Cabinet Secretary stated that an initial work plan for the lifespan of the MAB will be updated with more detail and to reflect discussions from this first meeting. This should also be shared externally.

• action: secretariat to refine the work plan for the duration of the MAB to include additional detail and incorporate thematic groupings of recommendations/commitments. Work plan to be finalised for next MAB in September and published

Board communication

Cabinet Secretary directed attention to the Communication and Engagement Plan paper which was circulated to members ahead of the MAB.

Cabinet Secretary emphasised that the MAB is committed to ensuring that lived experience is a core part of its work, and as such wants to carefully consider how best to engage with affected families.

Members discussed the importance of recognising the reality that no reform or change will ever bring back a loved one for affected families. Members also acknowledged that affected families have often not felt informed or involve by authorities.

Members recognised the individual experience and preferences of affected families; that some people may want to engage while others don’t; and that the preferred type and content of engagement may differ significantly. Members recognised that any experience shared would not tell the full picture or reflect one shared view.

Members were in consensus that engagement has to be on affected families’ terms, and that provisions need to be made to facilitate engagement in a way which suits them.  Options were discussed including the Chair going to meetings already planned, listening days and family testimonies.

Members also recognised that there are various pieces of work being done by different groups around the same time. We need to explore ways to align work where possible to ease the burden and ask on families, whilst enabling their unique and valuable input to be utilised to inform reform.

Members discussed some lived experience examples which highlighted instances of inconsistency and insensitivity in the way some family members are informed about the death of a loved one in prison custody. Members agreed that the prison Governor should directly inform the family as soon as possible, initially via telephone to facilitate urgent contact, followed by scheduled in-person engagement (assuming the family are content with this approach). Members acknowledged the importance of this engagement being open and transparent about what happened, so families do not feel as though information is being intentionally kept from them.

• action: secretariat to refine communication and engagement plan to ensure engagement with families is aligned to wider work
• action: secretariat to clarify with SPS what the process and practice is for informing a family of a death in custody and report back to members

Any other business

Cabinet Secretary advised members that the next MAB will take place in September, after summer recess. The date is currently under review to accommodate a longer timeslot and member availability. This will be confirmed by the secretariat in due course.

Cabinet Secretary thanked members for their time and contributions.

Meeting close