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

Annex C - Ways of Working Model

Each meeting focused on a specific theme, allowing recommendations and commitments related to that theme to be examined in more detail. Themes included: suicide prevention, information sharing, systemic change and bullying. Organisations responsible for delivering FAI recommendations were designated as Action Owners for MAB oversight purposes and were invited to attend formal MAB meetings to speak to progress relating to the relevant meeting theme.

Guest attendees who had undertaken specific pieces of work relevant to the scope of the MAB were invited to contribute to selected meetings. In September, Professor Graham Towl presented the findings of his independent review of Talk to Me^[15], the Scottish Prison Service’s suicide prevention strategy in place at the time of Katie, William, and Jack’s deaths. In February, Sheriff Principal Abercrombie attended to share his findings and recommendations from the independent review of Fatal Accident Inquiries (FAIs) relating to deaths in custody in Scotland^[16], providing valuable insight into the systemic issues identified and areas for improvement.

Minutes of the formal meetings were published on the MAB gov.scot webpage.^[17]

Progress reporting to the MAB

To enable the MAB to assess progress and hold action owners to account, action owners were required to submit progress updates to the MAB Secretariat before each formal meeting. These updates included current progress and key tasks completed, milestones achieved, risks or issues and plans to manage them, and a traffic light confidence rating (Red–Amber–Yellow–Green or RAYG) for each recommendation, applied using provided guidance. This guidance is available at Annex F of this report.

The confidence ratings were self-assessed by action owners; the MAB did not set or approve them but used them to understand perceived progress. Secretariat quality assured these self-assessments, discussing with action owners the rationale for each rating. The MAB would have benefited from more time to allow for a line by line review of these progress reports in session, but used the reports to probe action owners and inform judgements.

Two success levels were agreed between the MAB and Action Owners:

i. Base Compliance – essential actions to meet the recommendation

2. Additional Best Practice – steps beyond minimum requirements

Action owners were expected to provide timely, accurate, and transparent updates and the Secretariat supported them to do so. Action owners were encouraged to raise issues or considerations relating to implementation with the MAB, both by correspondence or in person when attending Board meetings.

The Secretariat collated progress updates from action owners into reports for the MAB, featuring: dashboard visuals and progress trends, detailed confidence ratings for each recommendation, highlights of successes, emerging risks, and issues for discussion. For ongoing recommendations, detail was requested about what specific actions were planned to deliver the recommendation. Reports were published on the website.^[18]

The MAB could request further detail or examine specific themes where more information was needed. The MAB contributed expertise in legal issues, human rights, operational delivery, public health, academia and family engagement to ensure fair, informed feedback.

Additional progress report meetings

In response to feedback from the MAB and action owners, additional progress report meetings were introduced from November onwards. These sessions were held online with actions owners and the MAB. The Cabinet Secretary did not attend. These additional sessions gave the MAB the opportunity to obtain additional information or clarification around specific actions, explore the basis for RAYG ratings, and seek assurance directly from those responsible for delivery. The meetings took place when reports were near-final, usually one to two weeks before a formal Board meeting, creating a feedback loop that strengthened the quality of information ultimately presented to the MAB. This approach aligned with the MAB’s Terms of Reference and supported its thematic workplan covering a wide range of reforms.

Site visits

In addition to meetings, two site visits to HMP & YOIs Polmont and Stirling provided opportunities for the MAB to observe the estate, engage with staff and young people in custody, and explore practical challenges in implementing FAI recommendations.

Insights from these visits informed MAB discussions on safety, wellbeing, and unintended consequences of risk-reduction measures. These visits were requested by the MAB and supported by SPS. The MAB did not have inspection powers; inspections are carried out by HMIPS, who publish separate reports following prison inspections.

Engagement with family members

The Ministerial Accountability Board (MAB) agreed as part of its terms of reference that it would communicate regular and coordinated updates to families to recognise and uphold the commitment to transparency.

While the MAB’s Terms of Reference included a commitment to provide regular, coordinated updates to families and to seek opportunities to hear their experiences, The MAB were acutely aware of the potential impact of further engagement on families already affected by trauma. It was noted that, while there could be general interest in the work of the MAB, many families known to the MAB or established support groups had not yet reached the stage of a Fatal Accident Inquiry and were therefore at different points in their journey to the core focus of the MAB. The MAB also recognised that this cohort represented a relatively small group and that other ongoing activities, such as the independent FAI Review, were actively engaging with families to gather their views and experiences.

To avoid placing additional burden or causing distress, the MAB did not therefore undertake separate direct engagement activities. Instead, families were signposted through pre-existing networks to dedicated webpages where updates and relevant information were published, ensuring transparency while respecting the principle of minimising harm.

The MAB noted the need for continued and systematic embedding of family feedback into ongoing implementation work. This includes ensuring families’ experiences of processes such as the 24 hour SPS concern phoneline and DIPLARs genuinely inform improvements, and that lived experience continues to shape how changes are felt ‘on the ground’.

Methods of Communication

• Families who were engaged with known networks such as the Deaths in Prison Custody Family Reference Group or a facilitated group based in Glasgow were notified by email about the MAB meetings and signposted to the webpages.
• Progress reports, minutes and all associated publications of the MAB’s work were published on the gov.scot website to maintain transparency.
• The MAB had limited engagement with people in custody during site visits to HMP & YOIs Stirling and Polmont to discuss anecdotally their experience. This helped contextualise evidence presented to the MAB but was not designed as formal outreach to prisoners. The MAB noted their aspirations to engage more with people in custody throughout the lifespan of the MAB and regret that this was not possible in the limited time they had available.

Family Listening Day

A member of the MAB (representing their organisation) and the secretariat, attended a Family Listening Day, commissioned by the Scottish Human Rights Commission and facilitated by Inquest in Glasgow in October 2025. This event provided a safe space for families to share their experiences following the death of a loved one in state care. The feedback highlighted recurring themes such as lack of support, broken communication, and delays. SHRC and Inquest prepared a detailed report from the day, which was published and shared with the MAB^[19]. It was agreed that the testimonies provided as part of the Family Listening Day provided enough detail that it would not be appropriate to ask the same families to repeat their testimonies to the MAB, in keeping with the principles of a trauma informed approach.

Direct Engagement

Family members attended formal MAB meetings in September and March. They were invited to see the oversight and accountability process in action and to contribute to the meeting in the way that felt comfortable for them. Their contributions provided valuable insight into their own experiences as bereaved family members as well as the long-standing challenges and systemic issues surrounding deaths in custody. These perspectives reinforced the importance of the MAB’s work and informed discussions on future priorities.