Fatal Accident Inquiries: Ministerial Accountability Board minutes - March 2026

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’
• 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

Additional Attendees

• Linda Allan 
• Scott Allan 
• Linda Pollock, Scottish Prison Service (SPS)
• Programme Executive, SPS
• Catriona Dalrymple, Scottish Government (SG)
• James McLellan, SG
• Denise Swanson, SG
• Unit Head for Healthcare in Custody, SG
• Ross McGuffie, Forth Valley Health Board (FVHB)
• Prison Healthcare Lead, FVHB
• Statistician, SG Justice Analytical Services

Apologies 

• 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
• Nicky Brown, Head of Service at PDSO (Public Defence Solicitors Office)

Secretariat 

• Scottish Government officials

Items and actions

Welcome and opening remarks

The Cabinet Secretary welcomed attendees and outlined the thematic focus of ‘bullying prevention’ for the final meeting of the Ministerial Accountability Board (MAB).

The Cabinet Secretary acknowledged the tragic death of a young man in HMP & YOI Polmont over the weekend and reflected hope that this increases collective resolve to change things.

Scottish Prison Service update on bullying prevention

Scottish Prison Service (SPS) provided an overview of their new strategic approach to bullying prevention in response to Recommendation 10 from Katie and William’s FAI determination.

• SPS acknowledged failures in the implementation of the existing ‘Think Twice’ anti-bullying policy. SPS also acknowledged the need for multi-agency engagement in developing a more effective approach and have collaborated with external specialists on this work
• work has progressed over the past year to develop a new strategy, including a literature review and a national staff survey. Lived experience input has also been gathered from those in custody, including young people, adult men and adult women, as well as families and friends of those in custody
• insights from this work indicate that bullying presents differently for different groups, with three distinct cohorts identified: young people, adult men and adult women. Young people often felt unsupported by inconsistent responses to bullying and young men can often be the perpetrator and victim of bullying. For women, bullying tends to involve psychological harm as opposed to physical violence, including emotional manipulation and social isolation. For adult men, bullying tends to be around the prison environment and social status, with apprehension around confidentiality in reporting concerns
• SPS have developed a new restorative and trauma-informed ‘CORE’ bullying prevention strategy representing the values of ‘care’, ‘opportunity’, ‘respect’ and ‘empathy’. It is built on the pillars of prevention, response, and reporting/information sharing
• subject to approval by the SPS Taskforce, this new strategy will be trialled in Polmont with young people initially, and will involve staff training and development. Learnings will inform refinements and wider roll out across other prisons
• SPS recognise the need for the overarching strategy to be tailored to meet specific needs of different prisons across the estate, as well as different cohorts of people in custody. Further research will support and inform bespoke implementation for adult men and adult women
• it was highlighted that bullying was a significant factor in Katie’s case and that intelligence reports were not actioned appropriately, particularly if they were made by a fellow prisoner
• SPS were asked what is being done differently now with regards to intelligence reports
• SPS acknowledged that intelligence reports were not handled well enough previously, but there is now greater emphasis on ensuring these are taken seriously. SPS have strengthened the handover process between first line managers when staffing shifts change. SPS have put in place processes to support staff to ensure they know what they should be doing and how they should be doing this. Intelligence reports are part of a suite of tools used to manage bullying, supported by wider information and partner working. SPS confirmed that the work being done on the new bullying prevention strategy would be subject to external assurance
• members reflected that the new approach sounds positive, but aspirational. SPS agreed it is aspirational and this is to reflect the commitment and desire to do things differently and provide better support to those in their care. The intention is to provide preventative support earlier before escalation to crisis point
• members suggested it would be helpful for SPS to map pathways for the actioning of a bullying concern, and to establish clear plans for how this will be monitored and evaluated.
• SPS also provided an overview of progress in relation to ‘active patrolling’ in response to Recommendation 7 from Jack McKenzie’s FAI determination
• in addition to the work to develop a new bullying prevention approach, SPS commissioned a review focussed on night-time safety protocols, incident management and supervision. This work examined current staff instructions, the effectiveness of patrol practices, and the adequacy of staffing levels during patrol and night shifts as well as identifying opportunities to strengthen the prevention and response to incidents during these periods
• a full review of Standard Operating Procedures was completed across the SPS estate to understand gaps in guidance and operational inconsistencies. Targeted site visits to Polmont were also completed including engagement with nightshift staff and young people in custody. This led to conclusions that written guidance was not sufficiently specific, meaning practice was often informal, not covered as part of staff training and informed primarily by peer-to-peer learning
• SPS have developed a phased improvement approach focussing on strengthening written guidance and staff training; reviewing nightshift staffing models; and embedding assurance processes to improve consistency
• one member asked SPS what their confidence level is around changing the culture around bullying. Linda Pollock, recently appointed as the next Chief Executive of SPS, stated she is very confident about the journey SPS are on and that there is clear commitment to change at all levels across the organisation, including senior leadership. She provided assurances around a cultural shift and passion to do things better

Justice Analytical Services update on deaths in custody data

Scottish Government (SG) officials provided an overview of work around the publication of deaths in custody data. This work was developed in response to the Independent Review of the Response to Deaths in Prison Custody publication in November 2021, which identified the need to improve the range of available data on deaths occurring in prison custody.

The work links data provided by SPS and the National Records of Scotland (NRS) to enable comparisons between rates of death in custody with those of the general public. The statistics provide an overview of high-level trends but do not consider contextual factors or individual circumstances.

The latest published report looks at data between 2012-13 and 2022-23, with an updated publication due imminently which will include data for 2023-24.

Based on the latest published data, there was 345 deaths in prison custody between 2012-13 and 2022-23. Probable suicides comprise the highest proportion of deaths in prison custody (around 30%), followed by diseases of the circulatory system (around 21%) and drug misuse deaths (around 15%). Overall, the statistics indicate that the risk of death in the male prison population was significantly lower than in the male general population; but the risk of suicide was higher, particularly in recent years.

• members agreed that this does not necessarily mean that people are safer in custody. The fact that mortality risk increases immediately upon release from custody suggests this is more an indictment of the conditions people experience outside of custody, rather than a reflection of the safety of custody itself

SG officials acknowledged that there are gaps in current data and analysis, particularly in relation to deaths involving drugs. Work is planned to incorporate this into reporting in future.

Members discussed whether these statistics are helpful for informing decision-making. It was suggested that additional contextual data could be helpful for informing risk factors, such as access to educational opportunities, recent family contact, length of time spent in custody, recent prescriptions etc. However, members acknowledged the resource constraints to capture and use such information meaningfully, emphasising the need for effective prioritisation around what information is gathered and what purpose it will serve. Members also acknowledged that particular trends or occurrences are challenging to capture statistically due to small numbers, such as people dying by suicide later in their sentences, and broader methods of suicide being apparent in recent years.

• SPS added that they use internal management information more than official statistics as this is broader and more readily available, so enables them to better understand and support individuals in their care. FVHB added that they primarily use multi-disciplinary meetings with partners to bring together wider information and support a more integrated approach to mental health support provision

It was suggested that language should be carefully considered to ensure it is appropriate and sensitive, including around drug-related deaths and the way trends are described.

Members also queried the suitability of independence of this work being done within government, since it came from a recommendation which explicitly cited the need for a wholly independent data source.

Progress report review

The Cabinet Secretary invited action owner representatives from SG, SPS and FVHB to provide progress updates. Comments were specifically welcomed around key work already delivered and areas still requiring further work.

Officials from SG provided an overview of areas primarily related to transparency and legislative reform. Work is ongoing to progress the ‘test of change’ model for the National Oversight Mechanism, which will focus on deaths in prison custody initially then be independently evaluated to inform the next phase. Procurement is progressing to establish a Family Advocacy service, with findings from the independent FAI review helping to inform this. There is ongoing engagement with UK government officials around improving legal aid provision for families involved in FAIs, and exploring the lifting of Crown Immunity. Work is also progressing to improve information sharing across justice with a compliance focus to ensure things are working as they’re supposed to be now. This includes obtaining assurances that reports which should be shared by courts are being received by prisons. A working group is being reconvened to consider broader systemic improvements in information sharing, including options for commissioning independent research in this area.

Officials from FVHB provided an overview of health-related recommendations. Revisions have been made to information sharing agreements to facilitate more effective communication, risk-management and care provision; and enhanced information training is now in place for staff. There is better and more proactive inter-disciplinary working in place, and a mental health colleague has been seconded to SPS to work collaboratively on the development of the new suicide prevention approach. Assurances were provided that where recommendations are considered ‘completed’, these are being continuously reviewed to improve effectiveness where possible. Resource remains a constraint, particularly in HMP & YOI Polmont due to the increasing population.

• FVHB officials reflected that the enhanced oversight of the MAB has been valuable for driving wider discussions and learning

Officials from SPS provided an overview of progress of their recommendations. A dedicated Taskforce was established to oversee delivery of this work, chaired by the SPS Chief Executive. Expertise was brought in to inform workstreams and supplement existing knowledge and experience. Those leading on workstreams have consistently been encouraged to develop greater and broader improvements beyond the scope of specific recommendations where possible. Demonstrable progress has been made in relation to designing and trialling a ligature audit toolkit to identify ligature risks in cells. An additional safeguarding process has been introduced where young people experience heightened observations for their first 72 hours in custody to support them in this vulnerable timeframe. An independent review of ‘Talk to Me’ was commissioned and has helped inform the development of a new suicide prevention approach, as well as a published ‘Commitment to Change’ document. These findings are also informing interim improvements while the new approach is being implemented, including minimising movements of people within and between prisons, and enhanced provision of psychological support services. SPS added that they aspire to widen reforms and learnings across their estate and adult populations where feasible.

• SPS officials acknowledged the need for greater assurances externally about how committed they are to a sustained effort to do things differently. They emphasised the need to balance accountability with delivery to enhance the pace of progress
• the danger of narrowly focussing on specific FAI recommendations was highlighted to SPS. For example, bunk bed removal may reduce ligature risks, however cell sharing may also be a protective factor in some cases if an individual prefers to share a cell and is not at risk of suicide. Personal agency is imperative and must be considered
• the Cabinet Secretary added recognition that population challenges in prisons are a barrier to systemic change 

Final reflections

The Cabinet Secretary welcomed final reflections from attendees and action owners on the work of the MAB.

Linda Allan reflected that she is proud of the legacy Katie’s campaign has produced. Young people must stop dying in state custody, but above that they should also thrive. A lot of work still needs to be done and ideally this change should happen at a faster pace. There is a need to keep asking the right questions, primarily ‘what does this young person need’? Linda expressed gratitude to those around the table for their shared desire to deliver change for the whole prison population.

The Cabinet Secretary reflected the importance of remembering that the justice system isn’t the end of the line – people should leave prison in a better position and with better prospects than when they arrived. All parts of government must work together to challenge issues around why Scotland has such high prison population rates. The MAB has helped to drive progress and she is confident that the work will continue to move forward.

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 closed

Post-meeting agreement

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

• members agreed with the direction of travel of the new SPS bullying prevention strategy. They support the aspirational nature of the new approach and the commitment to do things differently. However, they recognise that implementing the policy effectively will be fundamental to delivering meaningful change. Mapping out pathways for what this means for people in practice would be valuable. It would also be helpful for SPS to set clear plans for how things will be monitored and evaluated to make sure the new policy is achieving the desired outcomes
• regarding the JAS official statistics, members agreed there is great potential for enhanced collation and analysis of deaths in custody data. Using data to better understand contributory and contextual factors relevant to deaths in custody can provide useful information about risk factors which can be used to prevent future deaths or harm occurring. However, members also appreciate how resource burdensome this is so encourage effective prioritisation of what data is collected and why to ensure the data can effectively inform decision-making. There is also a need to ensure the data is sufficiently independent to objectively inform action. Members noted that the data must be useful to policy makers, and were not sure if that was currently the case with the official statistics presented to the MAB