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

8. Reflections and Learning

8.1 What can be done now

The MAB recognise that SPS, in particular, has invested significant effort into the FAI work through strong resourcing, governance and collaboration, and recognises the longer‑term ambition around strategic reform and systemic change. While the new policies such as Commitment to Change are promising, implementation is key, as past experience has shown good policies are not always being delivered well in practice.

The MAB would like greater assurances around how implementation of both current policies and any new policy will be improved. The basics of success are ensuring that policy commitment:

• matches available resourcing
• has been designed with care to ensure the policy is operationally practical
• is backed by a strong and united SPS leadership message that agreed change must be delivered
• includes the clear targets and the measurable data required to evidence delivery
• Prison Governors know that they will be accountable for delivery and there will be consequences if they fail to deliver

They would also have liked more assurances that action is being taken to keep prisoners safe in the interim before new policies are rolled out. This would demonstrate that there is a real collective cultural shift this time around.

Some practical suggestions are:

• Identify and share good practice across the SPS estate: review and highlight effective approaches observed in establishments, including trauma‑informed practice in institutions that are doing this well, using these as practical examples of what can be implemented quickly and without waiting for policy change.
• Strengthen data collection on local practice: systematically gather key operational data from all prisons, for example how often safer cells are used when individuals are placed on Talk to Me, to enable meaningful comparison, identify variation, and support targeted conversations about sites that may require focused improvement.
• Review and enhance the use of concern phone lines: proactively review and monitor the effectiveness of concern lines by gathering regular feedback from families and other stakeholders such as defence agents, assessing whether the lines are accessible and useful, and ensuring that any issues identified are addressed promptly.
• Monitoring drug prevalence: recognising the clear link between substance use and a significant proportion of deaths in custody, better data would allow earlier intervention and stronger local responses.

Professor Towl’s report^[14] on the review of Talk to Me also identified a number of recommendations that are not wholly dependent on full policy change and could be progressed quickly through strong leadership direction and managerial oversight. These practical interim measures could help mitigate harm and strengthen safety while the new “Commitment to Change” policy framework is being developed and embedded. For example:

• Safer cells were originally intended for exceptional circumstances but, in practice, had become routine. A clear leadership communication reinforcing their intended purpose and directing staff to use them proportionately could help phase out unnecessary reliance on these cells. Checking that Governors are complying with the “by exception” guidance would help understand how things are working on the ground.
• Safer clothing can undermine dignity and worsen trauma when used routinely or without sensitivity, especially for women. Leadership direction can help ensure it is only applied when genuinely required.
• Access to constructive and meaningful activity is identified as protective and central to suicide prevention. SPS’ leadership could emphasise that purposeful activity should not be unnecessarily restricted by suicide‑prevention processes and should be treated with the same importance as other healthcare‑related interventions.
• Prolonged isolation was found to heighten distress and increase vulnerability. Professor Towl recommends avoiding routine or automatic confinement under suicide‑prevention measures. Clear instructions can help staff maintain engagement and avoid isolating individuals unless absolutely necessary.
• Peer listeners and similar roles were described as underutilised despite their protective value. Expanding these schemes, improving training, and ensuring ongoing support would strengthen day‑to‑day emotional and practical assistance for those at risk.

The MAB is aware that the Scottish Government and SPS face unprecedented population challenges and that pressure is being put on the system because of this. Accordingly, the MAB felt it is even more important that the Scottish Government ensures that there is appropriate integration between the various workstreams which are handling prison population issues, bail and progression to the work on FAIs as there are many issues which will interconnect, and similar challenges will be being considered.

Further, the MAB felt obligated to say that the issues which are being raised within Forth Valley Health Board relating to the FAIs should be escalated to national forums so that learning can be shared and replicated. The MAB feel there should be stronger responses from Health to better support SPS. Professor Towl, for example, repeatedly highlights in his report that the current policy (Talk to Me) over‑relies on asking people directly whether they feel suicidal, and that we must look beyond what people say. Trained practitioners are well able to detect distress non‑verbally. Commitment to Change marks a clear shift away from the current Talk to Me model which is positive, but Health must play its part in making sure that it is able to be implemented properly and as intended.