Fatal Accident Inquiries: Ministerial Accountability Board minutes - September 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

Additional Attendees

• Professor Graham Towl
• Linda Pollock (Scottish Prison Service)
• Lorraine Roughan (Scottish Prison Service)
• Linda Allan

Apologies 

• John Reilly

Secretariat 

• Scottish Government officials

Items and actions

Welcome and opening remarks

Linda Allan delivered an opening statement to members of the Ministerial Accountability Board (MAB). This referred to a series of young deaths in custody over the past two decades, highlighting repeated failures in suicide prevention, delayed Fatal Accident Inquiries, and unimplemented recommendations. It called for meaningful change and accountability, not just in response to the deaths of Katie, William, and Jack, but for all those who died before and after.

Cabinet Secretary expressed appreciation for the powerful opening remarks. She acknowledged awareness that there will be more FAIs to come and remarked that the work of the MAB is a commitment to start building trust.

Polmont visit reflections

Cabinet Secretary stated that MAB members and secretariat officials visited HMP & YOI Polmont on 3rd September. The Governor, Tony Martin, hosted the visit, which was attended by Professor Sarah Armstrong, Nicky Brown and Dr Sarah Couper. The visit was at the invitation of the Governor and was planned in a way that would ensure minimal disruption to the operation of the facility whilst also offering an opportunity for as much openness and transparency as possible in evidencing the work underway to progress the FAI recommendations. The visit included discussion time with the Governor, as well as the opportunity to see cells and engage directly with prisoners.

Members who attended offered personal reflections on their experience.

Members expressed that some positive developments were evident in relation to delivering the recommendations and that the recommendations appear to be taken seriously by staff. In particular, the introduction of a 72-hour process whereby young prisoners receive heightened observation from admission for their first 72 hours in custody to reflect the increased risk evidenced by literature during this initial period was welcomed. Additionally, positive developments were evident in relation to ligature audits to enhance cell safety.

Members mentioned that unintended consequences were apparent following implementation of some changes. For example, toilet cubicle doors have been removed pending replacement with alternatives which reduce the risk of being used as ligature anchor points, however this negatively impacts on the human rights of young people who routinely eat all meals in their cells within close proximity to the toilet. Members discussed the wider issue around post-Covid legacy habits being normalised, including eating meals in cells as opposed to in communal areas. Members emphasised the importance of making prisons bearable and enabling opportunities for people to engage in activities out of their cells which interest them. Members also acknowledged that high prison populations and resource constraints are an impediment to this.

Members also reflected on comments from prison staff about the operational complexities and resourcing challenges associated with implementing some of the recommendations.

Members mentioned that anti-social behaviour and noise levels at night in Polmont was discussed during the visit. This was described as a relatively new problem which does not routinely occur across other prison estates. Members discussed the negative impact this may have on young people who are newly incarcerated and unfamiliar with the environment.

Members discussed the use of segregation and potential discrepancies in application, particularly in relation to drug-use, where segregation should only ever be used as a safety procedure to minimise harm whilst under the influence and not as a punishment.

One member mentioned that more time outside of the boardroom would have been welcomed.

• action: secretariat and SPS to refine itinerary for Stirling visit based on reflections from Polmont visit

Talk to Me overhaul

Talk to Me - independent review

Professor Towl presented findings from his independent review of ‘Talk to Me’ (TTM) which was commissioned by SPS as part of the SPS’s plan to overhaul TTM.

Professor Towl explained the extensive and varied methodology of the review to attain information which was as valid and reliable as possible within the agreed time parameters. The review included site visits to multiple prisons, a call for evidence, a literature review and extensive stakeholder engagement (including discussions with prison staff, prisoners and family members).

Professor Towl mentioned that attempts were made to visit seven prisons. Of these, visits were arranged for six prisons but there was one prison which did not facilitate access. Overall, gaining access to prisons was more difficult than anticipated, particularly for those with high suicide rates.

SPS attendees indicated that they would look into this.

Professor Towl provided an overview of the key findings of the review:

• ‘Talk to Me’ as a brand is irreparable, so a whole new approach and name should be developed
• implementation of the TTM policy has been a core problem and it seems to have been implemented differently than originally intended
• in practice, TTM seems to focus on three ‘pillars’ which each focus on physical prevention and taking things away from people in crisis: 1) moving people from standard cells into ‘safer cells’; 2) replacing standard clothing with ‘safer clothing’; and 3) initiating frequent observations

Professor Towl reflected that this approach constitutes acute management, and is not embedded in a broader strategy. There should be a greater balance between physical prevention, therapeutic intervention, operational considerations and clinical risk

There is a tendency to default to the ‘safest’, or most severe option during TTM case reviews (i.e. the most frequent interval for observations); however, this could be interpreted as the ‘safest’ option for the prison as opposed to the prisoner. Professor Towl reflected that some prison staff take this approach as they are worried about repercussions and becoming involved in a Fatal Accident Inquiry (FAI) if they do not take severe action and harm then comes to an individual.

Members reflected on the review findings and discussed similarities with their experiences of the FAI process.

• one member mentioned that from their experience, people in prison are routinely segregated as soon as they say they feel suicidal. This is contrary to policy which states segregation should only happen in exceptional circumstances and is another example of implementation of policy being the problem
• members discussed the wider FAI process. Specifically, how it feels adversarial to all involved (especially families who are often blamed) and encourages punitive, self-preserving behaviours. Concerns were raised about the potential lack of scrutiny of contributory factors to deaths in custody by not including things like general conditions within the prison environment and treatment of the individual within prison
• members agreed there must be a quicker and more effective way to look at issues and learn lessons
• Cabinet Secretary mentioned that these points were all valid and would be useful to the ongoing independent review of the FAI system being chaired by Sheriff Abercrombie. She committed to writing to key actors, including Sheriff Abercrombie, regarding the FAI process and its impact on prison culture

One member reflected on prison staff culture in relation to deaths in custody and highlighted a Freedom of Information request which revealed that only 13 prison officers were investigated internally by SPS following deaths in custody.

One member provided insight into the public health prevention model where primary, secondary and tertiary interventions are managed. When someone feels suicidal, early signs are evident, so primary prevention needs to be embedded more into mental health models in prisons to mitigate escalation to crisis point.

Members discussed frustrations at the focus on physical prevention. Previous research findings were highlighted which demonstrate that enabling people in prison to wear their own clothes, have increased time out of their cells, and interpersonal engagement all act as preventative factors to suicide. Members also discussed the disruptive nature of frequent observations, particularly through the night.

One member highlighted the importance of human engagement and mentioned a case example in a prison in England where Samaritans are allowed to spend the night in a cell with someone who is feeling suicidal, either chatting, engaging in activities or simply being present in their company. Members agreed this was a positive example of good practice which could be utilised in Scottish prisons.

One member referred to research (Making a Difference, by the New Zealand Ombudsman) which was conducted to identify whether there are any systemic issues that may be affecting the ability to achieve the significant and sustained change in a prison setting.

Concerns were expressed around expectations on nursing staff. Specifically, they often receive very limited training on suicide prevention but are often presumed to have specialised knowledge. This is amplified by the nuanced nature of suicide prevention in prisons compared to suicide prevention in general community settings.

• members agreed that wider use of health professionals with therapeutic backgrounds would be beneficial in prisons. Professor Towl added that psychologists in particular would be very beneficial and stated that they are rarely used in Scottish prisons

Concerns were also raised about the limited reach of Distress Brief Intervention (DBI) funding within prisons.

The Cabinet Secretary mentioned a cross-government ministerial group on prison health and social care could be helpful in progressing wider training across health professionals.

• action: Cabinet Secretary to engage with Sheriff Abercrombie and/or relevant justice stakeholders around the independent FAI review and the impact of the process on prison culture.
• action: Cabinet Secretary to engage with cross-government ministerial group to support training across health professionals.

Talk to Me – implementation of new approach

SPS representatives (Linda Pollock and Lorraine Roughan) discussed their proposed next steps to implement a new approach based on the Talk to Me review findings.

Although many of the recommendations specifically relate to Polmont, SPS stated their intent to implement reforms in Stirling too, since young people are in custody there, as well as across wider estates and prison populations where possible.

Work to design and implement a new approach to suicide prevention is underway via a dedicated workstream and involves a representative from the Samaritans. The initial focus will be on crisis response, and this will later be supplemented by a wider preventative model. The new approach will recognise the heightened risk associated with incarceration. There was recognition that the brand ‘Talk to Me’ is not repairable, so the new approach will bear a new name and reflect a shift towards a more therapeutic model.

SPS mentioned they are keen to engage affected families in the development of the new approach and welcome guidance from the MAB members on how best to do this.

SPS mentioned recognition of the cultural challenge associated with implementing the new approach and the importance of empowering staff to make clinically risky decisions.

Members discussed the proposed new approach, emphasising the holistic cultural change required to treat people in prisons as traumatised individuals and give them support which they may never have received in their lives before.

Members also discussed wider related issues.

• people often end up in prison because there is nowhere else for them to go, and there is a need for greater community-based solutions for mental health in Scotland
• there are often obvious diagnosable psychological conditions evident in young prisoners, but they have never received the right support or diagnosis earlier which may have prevented them being incarcerated
• there are delays in information sharing with prisons, with social work reports and medical records often taking ten days or so to arrive

Professor Towl proposed some pragmatic solutions which are already within the gift of SPS to implement. Firstly, to reduce movements within prisons as transfers within and between estates heightens suicide risk; secondly, to utilise psychologists more in prisons to focus on suicide prevention initiatives; and thirdly to hot-house specialised trainers around prison estates to enhance the quality and consistency of training delivered.

Progress report – thematic focus on suicide prevention

SPS representatives were present to discuss the recommendations they are responsible for delivering in relation to suicide prevention, with specific attention on recommendation 5 around personal items (also referred to as ‘items in use’) and recommendation 6 around bedding. An accompanying paper was provided to the MAB from SPS on bedding and a paper on items in use will follow by correspondence.

Items in use

SPS stated that evidence in relation to items in use is being reviewed and focus groups are being conducted in Polmont, including current and previous prisoners, led by the Governor. There is a need to balance the removal of personal items with wider support provisions and keeping a sense of normality for those in prisons especially young people.

Members acknowledged the potential knock-on impacts of removing personal items and need to consider this in the context of wider interventions and support.

Members discussed replacing some personal items with ‘safer’ alternatives, such as replacing belted dressing gowns with hooded, non-belted alternatives which would reduce the ligature risk.

Members also acknowledge the operational challenges associated with removing all possible ligatures and ligature anchor points; and suggested prioritising the removal of more obvious ligature risks while wider interventions and reforms are being considered.

• Professor Towl added that ligature removal in the cells of young people should be prioritised over adults due to the increased impulsivity evident in young people increasing the risk amongst this particular cohort

Bedding

SPS provided an overview of their research into possible alternative bedding options, concluding that no intermediate option is available at present. This research will be published by SPS for transparency.

Members discussed using anti-ligature bedding as standard across all cells, though agreed that the severe discomfort associated with this type of bedding meant this would not be feasible.

It was highlighted that an expert during the FAI reached the same conclusion that no intermediary option exists, however noted that better anti-ligature bedding options do exist and could be considered for use by SPS.

General discussion on wider progress report

One member queried Action 1 in relation to Deaths in Prison Learning and Audit Reviews (DIPLARS), specifically how SPS define a chair as ‘independent’.

• SPS confirmed that the chairs appointed are external to SPS and committed to sharing further details about who has been appointed
• members discussed concerns with the DIPLAR process and that they often feel like a superficial exercise as opposed to a genuine endeavour to learn lessons. DIPLARs often do not come across as independent and centre around avoiding blame or accountability. DIPLAR paperwork is not completed consistently or fully, and the experience is very challenging for prison staff
• SPS acknowledged these issues and referenced work which is ongoing to improve the process and culture. Endeavours are underway to enhance transparency, including exploring whether action points from DIPLARs can be published

One member asked SPS what happens as a result of the ligature audit toolkit, specifically whether cells would be taken out of use if issues were identified.

• SPS stated that it is not possible to remove all ligature risks from all cells and that the intention is to grade risks identified to prioritise removal of anchor points which pose the greatest risk

Members voiced a desire to discuss specifics within the progress report in more detail but acknowledged time constraints of the meeting. The secretariat agreed to explore solutions to facilitate more in-depth discussions of the progress report.

• action: secretariat to follow up with SPS for the paper on ‘items in use’
• action: SPS to provide further details about DIPLAR chairs appointed
• action: secretariat to facilitate more in-depth progress report discussions with MAB members

Meeting Close