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

6. Overall Progress of implementation

A total of 43 recommendations and commitments were tracked by the MAB during its lifecycle - this includes a number of sub-recommendations and recommendations counted twice where they appear in both FAIs.

6.1 Overall Progress

Overall, 39 of the 43 recommendations and commitments have demonstrated measurable progress and provided assurance that they will be delivered as planned or have already been completed.

At the time of publication of this report, 12 recommendations are self-reported as fully delivered. Of the remaining actions, 7 are reported as very likely to be delivered; 20 are on track but need some attention; and 4 are facing major risks which require urgent action to address. None are considered impossible to deliver.

A timeline is provided at annex D showing significant milestones that have been achieved in the lifetime of the MAB.

6.1.1 Progress by Action Owner

Scottish Prison Service (SPS) own the majority of recommendations and commitments which were tracked by the MAB. They are responsible for delivering 34 recommendations in total (including one where ownership is shared with Forth Valley Health Board). At the time of publication of this report, 9 are self-reported as fully delivered; 4 very likely to be delivered; 17 are on track but need some attention and 4 have major risks which are being worked through urgently. The majority of those that are on track are sub-recommendations of one overarching recommendation around reviewing and overhauling the ‘Talk to Me’ suicide prevention approach.

Scottish Government are responsible for delivering 1 recommendation and 6 commitments which were tracked by the MAB. At the time of publication of this report, 1 was self-reported as fully delivered; 3 are very likely to be delivered; and 3 are on track with additional attention being given to these.

Forth Valley Health Board (FVHB) are responsible for delivering 3 recommendations which were tracked by the MAB (including one where ownership is shared with SPS). At the time of publication of this report, 2 are self-reported as fully delivered. The one outstanding is jointly owned with SPS and relates to guidance and training around information sharing relating to suicide risk. This recommendation faces significant risks but urgent action has been taken to mitigate these.

The RAG rating for each recommendation and commitment is included in annex E. The full progress report produced for the final MAB meeting is published and can be viewed here: March Published Progress Report

6.2 The MAB recognise significant progress has been made in relation to:

• Addressing some physical ligature risks; removing specific door stops and bunk beds from cells where young people under the age of 21 are accommodated at HMP Polmont and HMP Stirling; developing and piloting a ligature audit toolkit which showed that the cells that were audited at HMP & YOI Polmont were shown to be a high risk environment.
• Delivery of an independent review of SPS' "Talk To Me" suicide prevention policy and publishing a commitment to change document.
• A new SPS bullying prevention strategy called CORE to replace the current “Think Twice”. This will be piloted with young people in HMP & YOI Polmont in the coming months and in the interim a youth work service provided by Kinetic Youth has increased within the prison from 5 to 7 days a week.
• SPS introduced a 72 hour enhanced observation process for all young people on admission, recognising the heightened risk during this initial period. The MAB highlighted the potential long‑term implications of placing every young person on TTM (or equivalent) during this time, as its direct link to TTM creates a permanent record that may influence future risk assessments. The MAB stressed the importance of ensuring records clearly reflect the context and purpose of these observations to avoid unintended consequences throughout a young person’s time in custody. The MAB note that SPS will review this process and propose refinements by the end of April 2026.
• Improvements to the Death in Prison Learning and Audit Reviews process, including considering the safety of physical environment in relation to deaths and all deaths in prison custody now being independently chaired.
• Forth Valley Health Board providing training to staff on improvements relating to information sharing, although The MAB also noted that while this training represents important progress, equivalent training for staff across other Health Boards and within the SPS would enhance consistency and strengthen whole‑system capability. The MAB note that an NHS Forth Valley Mental Health Nurse has been seconded to work on the suicide prevention team with SPS as of November 2025.
• The introduction of free Legal Aid for next of kin from the point of first notice being issued of a Fatal Accident Inquiry (with primary legislation required for further change). The MAB note that between April 2025 and 3 March 2026 there were 25 grants of legal aid made to bereaved family members.
• The development of an initial “test of change” for a National Oversight Mechanism of deaths in custody within prison custody settings, to be delivered by HMIPS. While the MAB acknowledge there has been significant scoping work this year, the MAB considered it a missed opportunity that the final model had not progressed in the time since the Independent Review of Deaths in Custody in 2021. They note that additional work will now be required to fully establish the model in the next Parliamentary term.
• The procurement and piloting of Signs of Life technology to provide additional safeguarding.

6.3 The MAB recognise progress is still to be made on:

• Standardising a process for sharing vital risk information about individuals between external agencies and the prison service upon admission. There has been no demonstrable progress in improving the electronic sharing of information or the underlying IT infrastructure during the lifespan of the MAB. However, the MAB acknowledges that resource constraints and operational pressures - including those arising from early release measures - have contributed to this lack of progress.
• Systemic and cultural change within all organisations dealing with people in custody in how vulnerable individuals are treated in custody, moving towards a more trauma-informed approach.
• Addressing wider gaps in wellbeing and mental health support, the MAB reflected on the Sarah Jane Riley FAI, which showed how acute distress was missed. Her case highlighted issues such as prolonged isolation, accumulating medication, and the impact of adverse parole decisions. The MAB received reports that some young people at HMP Polmont remained behind cell doors for up to 23 hours. The MAB received assurances that SPS were proactively increasing out of cell time throughout the life of the Board. More broadly, the MAB stressed the need for mental health support that goes beyond behavioural checks and considers factors like stage of sentence and hope for the future.
• Enough urgency within SPS around making sure practice complies with policy, particularly with the proposed overhaul of TTM. The MAB are not clear on whether there is an interim position being adopted whilst SPS develops the new suicide prevention policy and Commitment to Change.
• Designing a policy relating to young people’s access to personal items that could be readily used as ligatures, and balancing a crisis response approach and a wider wellbeing approach.
• Implementing alternative bedding materials (rip-resistant) for use by young people in HMP & YOI Polmont following research that no options are readily available within the current market, nor can a bespoke solution be innovated or produced.
• Family Advocacy and the offer of support to families following a death in custody. The MAB note that procurement activity for a Family Advocacy Service was underway at the time of writing their final report.
• The MAB note that Crown Immunity remains a reserved matter and while continued efforts have been made by the Scottish Government at both Ministerial and official level to engage with the UK Government on this, discussions have yet to take place.
• Duty of Candour, accepting that progress here is, in part, related to the ongoing work in relation to the UK Government Public Office (Accountability) Bill that was introduced in the House of Commons in September 2025.