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

2. Foreword by Ministerial Accountability Board

The preventable and tragic deaths of Katie Allan, William Lindsay (or Brown) and Jack McKenzie marked an overdue shift in how Scotland has responded to deaths in prison custody. Over the last year, the Ministerial Accountability Board (MAB) has probed and challenged the evidence provided to it by Scottish Government, the Scottish Prison Service (SPS) and the National Health Service (NHS). We have had the support of a dedicated and resourced unit within Scottish Government to compile evidence submissions, and monitor and track the progress of action owners. From the material provided to us, we have published progress summary reports for public transparency.

The joint Fatal Accident Inquiry (FAI) determination into the deaths of Katie and William prompted this new approach to monitoring compliance with recommendations. It is true that the FAI was unique in its depth of scrutiny and extensive determination. But the tragic circumstances that led to their deaths were not at all unique. They were systemic failures that predated Katie and William, evident in preventable deaths before them and, most regrettably, after them. Since Katie and William’s deaths in 2018, there have been 331 deaths, from various causes, in Scottish Prisons according to SPS published data^[1].

In her statement to Parliament^[2], following the publication of the FAI determination into the deaths of Katie and William, the Cabinet Secretary said:

“Accountability starts with acceptance, but it does not end there. Accountability must also result in answers and actions that lead to lasting change.

I again extend my heartfelt condolences to the families of William Lindsay and Katie Allan, and to all families who have been affected by a death in custody. I know that they do not want condolences or hand wringing. It is action that they seek, and it is such action that we will deliver.”

It has been clear to us throughout the course of the MAB that there is a commitment to implementing change across action owners. However, it is also our duty to report that progress in implementation of recommendations from Katie, William and Jack’s FAIs has not been sufficiently urgent. We have heard many explanations for why certain progress has been hindered due to capacity, financial, and statutory constraints, but in some cases the MAB feel these explanations are not satisfactory. Commitment alone cannot meet the standard set by the Cabinet Secretary or by the families whose loss prompted this work. Progress has too often been incremental where urgency was required.

The work of the MAB over the last year has brought challenge, scrutiny and oversight to the State’s efforts to uphold its most fundamental duty, the right to life for those in their care. This level of oversight has not previously existed in Scotland’s response to deaths in custody. It represents a shift from accepting recommendations in principle to actively tracking whether change occurs in practice.

While we acknowledge there is a significant programme of work underway to deliver meaningful change, it is still unclear how these policy reforms will translate to safer practice on the ground. This will require careful management and close independent oversight.

The MAB is grateful to the team of officials who supported our work. They demonstrated professionalism, sensitivity and diligence. We are also grateful to the SPS, NHS and Scottish Government for the constructive way they have engaged with this new and, at times, challenging process. While we all have different roles in the system, we have the same goal – that all preventable deaths are avoided and no more families must go through the unimaginable pain of losing a loved one in prison.

To achieve that goal, robust scrutiny must continue, and we are heartened to see that as the MAB stands down, a new mechanism will take forward the independent oversight of progress, ensuring that scrutiny and accountability continue.

Sam Gluckstein

Philip Wheatley CB

Sarah Armstrong

Nancy Loucks

Sarah Couper

Nicky Brown