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

9. Reflections and Learning

The work of the MAB has demonstrated the value of structured, independent scrutiny operating alongside government and delivery bodies. Regular reporting, thematic discussion, and public transparency created momentum that may not otherwise have been sustained.

At the same time, the MAB’s time-limited nature highlighted limitations. Meaningful scrutiny requires time to interrogate evidence, test assumptions, and observe whether changes embed into practice. Reliance on self-reported progress, while necessary within the MAB’s remit, reinforced the importance of future oversight mechanisms having stronger analytical capacity. The MAB were repeatedly struck by the tension between the urgency conveyed by families and FAIs, and the pace at which institutional change occurs.

The MAB’s discussions, based on their experience of FAIs in general, reinforced that many of the failures identified were not technical or procedural but cultural. For example, information existed but was not shared; risks were minimised or recognised but not escalated; policies were in place but not consistently applied. Learning from deaths in custody therefore requires cultural change as much as policy reform.

To effect systemic change, learning and improvement must be continuous. FAIs, reviews and inquiries provide moments of clarity, but lasting improvement depends on mechanisms that routinely capture, analyse and act upon emerging risks. The development of a National Oversight Mechanism offers a welcome opportunity to embed this principle, ensuring that learning becomes an ongoing function of the system rather than a response to tragedy.

The establishment of the MAB marked an important shift in Scotland’s response to deaths in custody. While meaningful progress has been made, the MAB’s experience underscores that lasting reform depends on sustained leadership, independent oversight, cultural transformation and a continued commitment to transparency.

The ultimate measure of success will not be the completion of recommendations, but whether fewer families experience the loss that brought about this work.