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

7. Key Observations by Topic

The MAB made the following key observations based on consideration of all the information they have had access to in the previous 10 months.

7.1 Sustained leadership commitment

The MAB noted a clear and positive shift in the tone of assurances provided by SPS executive colleagues over the life of the MAB. They welcomed the ambition of leadership to create a more open, vulnerable and supportive environment for prison staff to feel confident in their roles and build supportive relationships with people in their care.

The MAB observed that the effective implementation of policies across the prison system depends on sustained and bold SPS leadership commitment. The MAB emphasised that without comprehensive staff training and robust supervision, there is a risk of repeating earlier shortcomings. The MAB considers that cultural change, rooted in the principle that deaths in custody are not inevitable, must be consistently modelled and reinforced at all levels.

7.2 Evidence Based Approaches and alignment with National Suicide Prevention Policy

The MAB noted a clear and ongoing tension between approaches focused primarily on restricting access to means of self‑harm and those that emphasise a therapeutic, holistic model of care. The MAB reiterated that suicide prevention in custody should align fully with the evidence base underpinning wider NHS and Scottish Government suicide prevention strategies.

The MAB recognised that this position reflects the recommendations set out in Professor Graham Towl’s review of the Talk to Me (TTM) strategy, supporting consistency of principles and expectations across justice and health settings. The MAB were clear that suicide prevention efforts must be grounded in trauma‑informed practice, with mental health and wellbeing as the central focus rather than reliance on environmental controls alone. The MAB considered this approach essential for reducing risk among both young people and adults in custody. The MAB welcomed SPS’ recognition of these principles and a direction of travel in its Commitment to Change that moved beyond punitive or crisis response modes.

7.3 Removal of personal items and bedding safety

The MAB noted SPS’ ongoing review of items in use, including work with focus groups involving individuals currently or previously in custody at HMP & YOI Polmont. In its September discussions, the MAB highlighted the need to balance the removal of personal items with preserving a sense of comfort and agency, particularly for young people.

The MAB recognised the potential for unintended consequences where restrictions are applied without broader mental health and wellbeing support. The MAB encouraged a proportionate approach, including the replacement of certain items with safer alternatives, such as non‑belted dressing gowns, while longer‑term policy is developed. The MAB note that SPS reported non-belted dressing gowns are now in place at HMP Stirling and belts and dressing gown cords removed from HMP & YOI Polmont.

SPS provided an update to the MAB on research into alternative bedding materials (rip-resistant) options^[12]. The MAB acknowledged that no suitable intermediate solution is currently available. The MAB further agreed that the discomfort associated with existing anti‑ligature (safer) bedding renders its universal use impractical. The MAB noted that the March progress report provided to the MAB stated that SPS will continue to explore alternatives to standard bedding in future and will seek to balance safety with trauma-informed care.

7.4 Resource and capacity constraints

The MAB noted that financial pressures remain a significant risk factor across several workstreams. Concerns were raised regarding the demands created by the 72‑hour admission process and the resulting impact on the Multi-Disciplinary Team within NHS Forth Valley, which has significantly increased due to the ripple effect of applying 72‑hour TTM to every admission. The MAB requested further clarification on how these pressures will be mitigated.

NHS Forth Valley assured the MAB at the March meeting that all cases for mental health support classified as urgent are being seen by a mental health nurse within 48 hours. Routine cases are seen within 7 days. Plans are underway for in-cell telephony where individuals in custody will be able to contact the NHS directly for health support. A business case has been submitted to NHS Forth Valley and SG seeking to uplift the resourcing for healthcare teams in HMP & YOI Polmont and HMP Glenochil.

7.5 Independent Review of Fatal Accident Inquiries

Sheriff Principal Abercrombie presented his independent review of deaths in custody Fatal Accident Inquiries (FAIs) to the MAB in February, stressing the need for clearer, prevention focused findings, quicker completion, and stronger separation between independent investigations and implementation. The MAB recognised these themes as consistent with its own concerns about the need for a more preventative, system‑wide approach, improved transparency, and better early investigative capability. The MAB noted the current lack of specialist expertise in the pre‑FAI phase and suggested that models such as Ombudsman‑led investigations^[13] or approaches used in other safety critical sectors could offer useful comparisons.

Sheriff Abercrombie recommended that, for now, the Crown Office and Procurator Fiscal Service continue leading FAIs within set time limits, supported by a new specialist unit within Police Scotland. The MAB broadly accepted this but highlighted gaps, including limited police expertise in the prison context and insufficient focus on systemic and human rights issues. They emphasised the need for cultural change, noting that the system can feel overly adversarial and focused on mechanics, rather than underlying causes. The MAB welcomed the proposal for a three‑year review of any new arrangements to assess progress and determine whether a more independent model should be considered, supporting early reform alongside ongoing evaluation and adaptation.

7.6 Information sharing

The MAB noted that longstanding problems with information sharing continue to place significant pressure on the justice system, particularly for vulnerable individuals entering custody. Legislative complexity, inconsistent court processes and unpredictable remand admissions mean risk critical information is often incomplete on arrival. The MAB recognise that this issue would not have been easily resolved in the 10 months they provided oversight, but nevertheless stressed the need for coordinated leadership and urgent interim measures to strengthen assurance, clarify roles and support staff ahead of a digital solution not expected until 2027. The MAB also emphasised that cultural changes, such as routine concise case summaries and closer collaboration with defence solicitors, are as important as structural reform.

The MAB further observed major gaps within court processes. In many courts, key reports are unavailable due to limited professional support, and only a small proportion of fitness‑for‑custody assessments are commissioned directly by the court. Most are arranged by defence solicitors, with no requirement for the Crown or court to share this information with prisons, meaning SPS often receives it only when they actively request it. The MAB noted that although defence agents frequently obtain reports containing important risk information, there is no consistent mechanism to ensure these reach SPS, leaving critical gaps at the earliest stage of custody.

7.7 Bullying prevention

The MAB expressed frustration at revisiting issues which had persisted in prisons for decades and stressed that implementation remains the core challenge. While the strategic direction proposed by SPS appears sound, the approach is high‑level, and the MAB felt it would be useful to understand how this will translate into practice and what is being done differently in the interim.

There was disappointment that SPS did not have key data available during discussions raising questions about whether indicators such as safer cell use among young people, bullying reports, and response rates are being routinely monitored. The MAB agreed that mapping the pathways and outlining what they mean in practice, alongside clear plans for monitoring, evidencing progress, and evaluating outcomes, will be essential.

7.8 National Oversight Mechanism

Over the past year, the MAB has provided temporary oversight while the Scottish Government progressed a phased, evidence led review of how a National Oversight Mechanism (NOM) for deaths in custody should be established. This work examined independent findings, engaged stakeholders and assessed a range of delivery models, including new structures, expanded roles for existing organisations and interim options that could strengthen scrutiny without immediate legislation.

Following this appraisal, the Scottish Government concluded that the NOM should be hosted within HMIPS, initially as a test-of-change, focused on deaths in prison custody. The MAB noted that this approach enables early progress, offers an initial phase to understand future requirements for potential expansion and will be refined through engagement with partners, families and representative groups. Officials confirmed that a supporting assurance structure will inform future decisions on extending the scope of the NOM beyond prisons, creating a standalone statutory body.

The MAB welcomed the proposal and emphasised that, although the NOM will not reinvestigate individual deaths, it must be able to scrutinise investigations, identify systemic issues and incorporate human rights considerations. The MAB supported the development of a flexible data tracker capturing a broad range of regime, health and case information, while cautioning that this should not reduce other agencies’ responsibilities. They agreed that beginning in prisons is a practical first step, noted potential challenges in expanding oversight to other settings and stressed the importance of clear communication with families.

The MAB also welcomed assurances that this test phase is temporary and intended to inform decisions on future structure and possible statutory powers. Overall, the MAB supported the focused test of change within HMIPS as a means to strengthen oversight, improve data quality and provide evidence for future reforms.

7.9 Family Advocacy

The MAB have been keen to be kept updated on progress regarding the Family Advocacy Service procurement activity and timeframes for implementation. The MAB heard that the Scottish Government have ensured that the experience of bereaved families have been at the core of a design of the family advocacy service with engagement taking place at the earliest opportunity to ensure that the approach to this service was shaped by the families. The MAB note that the aim of the Family Advocacy Service is to enable families to have independent trauma informed support and guidance following the death of their loved one.

The MAB note that the Invitation to Tender for this service was issued week commencing 16 March 2026. The MAB note that this will ensure that the contract can be awarded as soon as practical at the start of the new parliamentary session.

7.10 Transparency and access across the Prison Estate

The MAB recognised that the Scottish Prison Service (SPS) engaged throughout the MAB’s programme of work. The MAB observed that SPS shared progress updates and information quickly, supported requests from the MAB, and welcomed the MAB to prisons for site visits.

Against this, some defensiveness around SPS’ handling of the TTM review was also observed with disappointment. During the September meeting, it was noted that Professor Towl had been able to visit five prisons as part of his independent review of Talk to Me, but he highlighted difficulty in gaining access to one prison. Professor Towl noted that in general, access to some prisons, particularly those with higher numbers of self‑harm and suicide incidents, was more difficult to secure than expected. The MAB were disappointed to hear this.