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

Annex A - Terms of Reference

Background

On 17 January 2025, Sheriff Simon Collins KC issued his determination following a joint Fatal Accident Inquiry (FAI) into the deaths by suicide of Katie Allan and William Lindsay (or Brown), which occurred at HM Prison and Young Offenders Institution Polmont.

The Scottish Ministers response to the FAI determination was published on 13 March 2025. This response accepted all recommendations relating to SPS and Scottish Ministers covering themes including the prison cell environment and ligature risks, suicide prevention policies, information sharing between courts and prisons, staff training and learning from previous incidents. The Cabinet Secretary for Justice and Home Affairs (CSJHA) has also made the additional commitments, as follows:

• Legal Aid for bereaved families participating in FAIs
• An Independent review of the FAI process
• Pursuing lifting SPS’s Crown Immunity under health and safety law and exploring further transparency measures
• Establishing a National Oversight Mechanism
• Providing Family Advocacy for bereaved families

Purpose

The remit of the Ministerial Accountability Board (MAB) is to provide a single point of coordination, monitoring, and accountability for the implementation of the package of reforms required across stakeholders. The MAB will oversee the delivery of these recommendations and commitments, and the MAB will provide expertise to the Chair to support analysis and scrutiny of progress.

In its role, the MAB will model collaborative leadership, working to build trust in the system and providing both support and challenge to drive the effective delivery of recommendations. It will adopt a support and challenge function, working collaboratively with stakeholders to track and drive implementation at pace.

Roles and Responsibilities

The MAB’s role and responsibilities include:

• oversight of delivery of all actions, ensuring progress aligns with the agreed reforms
• holding Action Owners to account by having authority to request regular reporting and measurable progress
• ensure independence in oversight by providing independent expertise and scrutiny of progress
• communicate regular and coordinated updates to relevant stakeholders and families

The MAB will not:

• directly involve itself in operational delivery decision making, ministerial decision making or replace/impede existing accountability mechanisms (including Accountable Officers)
• have direct control over financial or budgetary matters, however, it may play a role to influence and support existing processes where appropriate

The MAB will be a formal, standing body with an initial lifetime of 10 months, after which its continued operation will be reviewed. The MAB is intended to be a temporary measure introduced in advance of establishing a fully independent National Oversight Mechanism for all deaths in custody.

To enable the MAB to fulfil its oversight function, it will engage closely with the relevant Action Owners and stakeholders responsible for delivering and implementing the associated reforms. Action Owners identified in the recommendations from Katie and William’s FAI determinations are:

• Scottish Prison Service (SPS)
• Forth Valley Health Board (FVHB)
• Scottish Ministers (via Scottish Government officials)

If further recommendations are considered by the MAB over time, additional Action Owners and stakeholders may be identified and brought into the oversight process as appropriate.

Scope

The Ministerial Assurance Board (MAB) will have strategic oversight of the implementation of recommendations arising from the Fatal Accident Inquiry (FAI) determination into the deaths of Katie Allan and William Lindsay (Brown). This includes oversight of the delivery of associated commitments made by the Cabinet Secretary in statements to the Scottish Parliament in January and March 2025.

This particular FAI determination was unprecedented in the volume and specificity of its recommendations and has driven a significant programme of reform. The MAB’s establishment reflects a need for enhanced transparency, accountability, and cross-sector coordination in response to these recommendations.

The core scope of the MAB will focus on:

• implementation of recommendations from the Katie Allan and William Lindsay (Brown) FAI determination
• deaths by suicide involving ligature within the prison custodial environment

While the MAB’s primary focus is on this determination, it recognises the broader context of deaths in custody and the impact on other individuals and families. As such, the MAB may, where appropriate:

• hear testimony from families affected by deaths in custody, recognising that their experiences may involve a range of circumstances
• facilitate discussions on the wider policy and operational implications of the recommendations, including cultural and systemic reform across the prison estate
• support work that considers longer-term change to reduce preventable deaths in custody
• consider incorporating recommendations from additional FAIs published during the MAB’s lifespan, particularly where there is significant thematic alignment, such as, but not limited, to ligature-related suicides in prison custody

Deaths that occur in non-prison settings, such as police custody or deaths involving other causes (e.g. drugs-related fatalities), are out of scope for the MAB. However, lessons learned through the MAB’s work may help inform future cross-sector improvement efforts.

The MAB will not revisit the FAI recommendations themselves but will focus on supporting and scrutinising the effective implementation of reforms intended to improve outcomes and reduce the risk of future harm.

MAB Membership

The membership of the MAB is at the invitation of the Cabinet Secretary for Justice and Home Affairs, who will Chair the MAB.

The MAB are expected to represent their organisations or peer groups, contributing their expertise and perspectives openly and freely.

The MAB will seek to include lived experience into its work, ensuring that the voices of those directly affected by a death in custody or the reforms to be implemented remain central to its discussions and oversight.

The MAB members are expected to declare any personal or professional interests at the outset of the process. If any member is uncertain about whether an interest should be declared, they should seek guidance from the Secretariat.

The MAB are required to recuse themselves from any discussions or decisions where they have a conflict of interest.

External stakeholders may be invited to present to the MAB or attend as observers at the Chair’s discretion. These stakeholders may provide additional expertise or offer perspectives that enrich the MAB's deliberations.

Frequency of meetings

The MAB will convene for a total of approximately 6 meetings to be held within the following months:

• June
• September
• November
• January
• March
• April

Meetings may be scheduled or cancelled at the discretion of the Chair, should circumstances require it. Outside the standard meeting cycle, the MAB may also receive information by email, inviting feedback or offering opportunities for discussion and input on relevant matters.

Logistics and secretariat

Secretariat support for the MAB will be provided by the Scottish Government’s Oversight and Implementation Unit within the Community Justice Division who can be contacted at oversight.implementation.unit@gov.scot.

The Secretariat is responsible for organising meetings, maintaining and sharing documentation, coordinating communication, and providing support to the Chair and the MAB as needed.

Board meetings will preferably take place in-person in Edinburgh. Hybrid/virtual arrangements will be put in place where necessary.

Papers will be shared with the MAB in advance of each meeting. The Secretariat will endeavour to circulate these at least three working days before each MAB meeting and the MAB are expected to read these in advance of the meetings to facilitate effective discussion.

The Secretariat will be responsible for minute-taking to capture key points and actions. The Secretariat will share these with relevant stakeholders, including the MAB, and will endeavour to do so within five working days following each MAB meeting.

Confidentiality and data protection

To ensure a safe, transparent, and productive working environment, all members must adhere to strict confidentiality protocols, especially when discussing sensitive information such as individual cases, data related to prisoners, or family details.

The MAB are expected to maintain the confidentiality of any sensitive information shared within the MAB’s meetings, ensuring that discussions are limited to those authorised to access such information.

Any documentation containing sensitive personal or operational data will be handled in compliance with relevant data protection regulations, ensuring that the privacy of individuals is respected.

Any breach of confidentiality should be reported to the Secretariat immediately, and the necessary corrective actions taken.

All papers submitted to, or produced by the MAB may be subject to the provisions of the Freedom of Information (Scotland) Act 2002 and may be disclosed in response to a request, unless an exemption applies.

Reporting

For transparency purposes, information about the MAB will be published on the Scottish Government website. This will include details of core membership, minutes from each board meeting, and the finalised terms of reference. Progress updates may also be published during the MAB’s lifecycle, as well as additional materials at the discretion of the MAB.

The MAB will produce a final report outlining progress against its objectives, a summary of the recommendations and actions achieved and any outstanding work. This report may be submitted as part of an update to the Scottish Parliament and may be made publicly available to ensure transparency, subject to the Chair’s agreement.

Review and evaluation

After 10 months, the effectiveness of the MAB will be reviewed to assess whether its ongoing role is necessary or if adjustments should be made to the structure, scope, or membership.

The review will take into account:

• The MAB’s impact on the delivery of the recommendations and related commitments
• feedback from relevant stakeholders
• the extent to which the MAB has driven independent oversight and accountability
• the structures available to transition any outstanding or legacy work from the MAB