Fatal Accident Inquiries - prison custody deaths: Ministerial Accountability Board - final report

1. Foreword by Cabinet Secretary for Justice and Home Affairs

The deaths of Katie Allan and William Lindsay (or Brown) were tragedies that should not have happened while they were in the care of the state. Their families, and many others, have campaigned tirelessly for recognition of the series of deaths in custody that have occurred over the past two decades, highlighting repeated failures in suicide prevention, long waits for Fatal Accident Inquiries, and unimplemented recommendations. Their efforts, and the unprecedented nature of Sheriff Collins’ FAI determination, called for meaningful change and accountability, not just in response to the deaths of Katie and William, but for all those who died before and after.

Last year, I fully accepted Sheriff Collins’ extensive recommendations and made a clear commitment to drive forward reform and strengthen accountability. Transparency is central to this work; it enables accountability which drives action, and it is action that delivers change. The Ministerial Accountability Board (MAB), which I established, provided an oversight mechanism to uphold that commitment to scrutiny and openness.

Over the past ten months, the MAB has provided oversight and reviewed assurances of progress. This report sets out a detailed summary of that work, including key findings and recommendations from the independent board members. In our discussions, I was particularly struck by the recurring theme raised around the gap between good policy and good practice and that is something we have yet to get right. That is a gap that needs to be closed and I am hopeful that the actions we have taken this past year are a step towards that.

Sheriff Principal Abercrombie’s independent review of Fatal Accident Inquiries relating to deaths in custody has also played an important role in shaping the next phase of work and I was pleased to welcome him and hear his contributions at one of the MAB meetings. His clear and practical recommendations, focused on reducing delays, strengthening accountability and ensuring that findings lead to meaningful action, provide a strong foundation for improving the experience of families and driving system reform.

I extend my sincere thanks to the members of the MAB for their time, expertise, and candour in providing independent advice. I also thank all staff within the Scottish Prison Service, NHS Forth Valley and Scottish Government for their ongoing commitment to delivering improvement. Most importantly, I acknowledge the families who have lost loved ones in custody for their tireless efforts to demand change.

This administration has been and remains committed to delivering the justice and accountability that families have every right to expect. While it is vital to deliver on each recommendation, real and lasting change requires transformation of the system and the culture that underpins it.

Over recent months, we have laid the foundations for meaningful and lasting progress. While the early stages of change can feel gradual, experience shows that momentum gathers quickly once the right structures and commitment are in place. We are now at a point where we must shift up a gear, building on the strides already made and accelerating our efforts with determination and clear focus. Our commitment is clear: to maintain progress, strengthen what we have established, and deliver the outcomes we are collectively working towards.

Looking ahead, lessons learned from the MAB and the key observations noted in this report will help inform the development of a National Oversight Mechanism to embed stronger transparency, learning and accountability across the system. This will ensure that the progress made under the MAB is sustained, that oversight does not diminish once the MAB concludes, and that the lessons from past failures drive lasting, systemic improvement.

Angela Constance MSP

Cabinet Secretary for Justice and Home Affairs