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

5. Introduction

5.1 The establishment of a Ministerial Accountability Board

The Ministerial Accountability Board (MAB) was established in June 2025 to provide a single point of coordination, monitoring, and accountability for the implementation of a comprehensive package of reforms committed to by the Scottish Prison Service (SPS), Scottish Government and Forth Valley Health Board (FVHB) in response to the joint Fatal Accident Inquiry (FAI) into the tragic deaths by suicide of Katie Allan and William Lindsay (or Brown) that occurred at HMP & YOI Polmont in 2018.

The MAB was time limited and did not have any formal powers to compel action owners to provide information to it. Instead, an expectation was set that a transparent audit would be made available to the MAB on progress in delivering on the recommendations and associated government commitments. The MAB challenged and scrutinised information and assurances submitted to it, relying on self-reported progress from action owners.

5.2 Governance Framework

The work of the MAB sits within a wider governance framework designed to ensure that recommendations from Fatal Accident Inquiries (FAIs) and related reviews translate into meaningful change. The three main components of this framework are set out below.

5.2.1 Reporting to the Scottish Parliament

The progress reported to the MAB informed regular updates to the Scottish Parliament to ensure accountability and public transparency. These updates provide assurance that progress on implementing FAI recommendations and related reforms is monitored at the highest level, supporting confidence in the system and enabling parliamentary oversight of key developments^[10][11].

5.2.2 SPS National Taskforce for Prison Welfare and Safety

Chaired by the Chief Executive of the Scottish Prison Service, this Taskforce brings together senior representatives from partner agencies including the NHS, Scottish Government, and SPS Trade Union Side. Its remit is to oversee the delivery of FAI recommendations and drive coordinated, cross-agency action to improve welfare and safety across the prison estate. This is the main vehicle through which SPS reported its progress to the MAB.

5.2.3 Independent Scrutiny and Future Oversight

His Majesty's Chief Inspector of Prisons for Scotland is responsible for inspecting the 17 Scottish prisons to assess prisoner treatment and conditions, and for reporting publicly on the findings. The Chief Inspector has also held overall responsibility for prison monitoring, delivered daily by independent monitors since August 2015. On 24 March 2025, the Cabinet Secretary for Justice and Home Affairs instructed the Chief Inspector to investigate issues highlighted in the Fatal Accident Inquiry into the deaths of Katie Allan and William Lindsay, with a focus on how young people at Polmont are supported and protected from suicide risk. HMIPS reviewed outcomes for people in custody, briefed the MAB in February 2026 on findings from their August 2025 visit to HMP & YOI Polmont, and published their report on 23 March 2026 which can be found on their website here: HMIPS Report on visit to HMP and YOI Polmont.

5.3 MAB Membership

Six individuals were approached by the Cabinet Secretary for Justice and Home Affairs and invited to sit on the Ministerial Accountability Board, in recognition of their independent experience and knowledge in relation to the issues raised in Sheriff Collins’ FAI determination. The MAB held a range of experience from third sector, legal, operational, research and health backgrounds. All individuals accepted the invitation to join. Secretariat was provided by the Scottish Government. The Cabinet Secretary for Justice and Home Affairs, Angela Constance, sat formally as Chair.

The MAB were:

• Sam Gluckstein - Head of UK National Preventive Mechanism (later Senior Expert Adviser on OPCAT implementation to the Office of the Inspectorate of Prison (and detention designate) Ireland), with expertise in OPCAT implementation and prison inspection.
• Sarah Armstrong - Professor of Criminology, University of Glasgow; SCCJR researcher; co-author of “Nothing to See Here”, with extensive experience in criminology and engagement with bereaved families.
• Phil Wheatley CB - Former Director General of HM Prison Service and National Offender Management Service, bringing operational insight and experience as an expert witness in Fatal Accident Inquiries.
• Professor Nancy Loucks OBE - Chief Executive of Families Outside; co-chair of the Independent Review into Deaths in Prison Custody, with strong links to family engagement and continuity in review processes.
• Dr Sarah Couper - Lead Consultant for Mental Health, Public Health Scotland, with specialist knowledge in mental health and suicide data in Scotland.
• Nicky Brown - Head of Service, Public Defence Solicitors Office (PDSO), with over 30 years’ experience as a solicitor and expertise in legal safeguards and representation of prisoners’ interests.

Board discussions were conducted within the context of the MAB’s oversight role, focusing on scrutinising progress and drawing on the professional expertise and experience of its members. The views expressed during these discussions and within this report reflect the independent perspectives of members and do not necessarily represent the position of the Scottish Ministers.

5.4 MAB Terms of Reference and scope

At its inaugural meeting in June 2025 the MAB agreed primary focus should explicitly be on the recommendations related to the prison custodial environment only. However, the MAB noted that this work should serve as a catalyst for broader reforms concerning all deaths in custody. The MAB emphasised a strong scrutiny role, agreeing that assurance of progress would be sought through the provision of information and details about delivery plans and completed actions, potential site visits, and attendance from action owners. The formal Terms of Reference as agreed and published are available at Annex A.

As part of the agreed scope the MAB were able to consider incorporating recommendations from additional FAIs published during the MAB’s lifespan, particularly where there was significant thematic alignment, such as, but not limited to, ligature-related suicides in prisons holding young people. Recommendations from one additional FAI were incorporated on this basis, relating to the death of Jack McKenzie at HMP & YOI Polmont in 2021.

The MAB met formally five times over ten months (June–March) following the work plan set out in Annex B and to the ways-of-working model set out in Annex C.