Independent Review of the Response to Deaths in Prison Custody - Second progress report

Second progress report by Gillian Imery, External Chair to provide a further update two years on from the publication of the Independent Review of the Response to Deaths in Prison Custody in respect of the implementation of the recommendations and advisory points made by the Review.

3. Other ongoing improvement work

Police Scotland:

  • Members of the DiPCAG identified that there was a need to convene a national governance group to promote more effective working more generally across different organisations and consider the quality of investigations into deaths in prison custody.
  • Chaired by the Police Service of Scotland, a Deaths in Prison Governance Group has been created that met for the first time in August 2023. Agencies represented on this group include Police Service of Scotland, SPS, COPFS and NHS. The group agreed a Terms of Reference and will meet quarterly in the future. The group shared areas of good practice and explored key aspects of future learning. The key aims of this group were agreed as:
    • develop effective processes, governance arrangements and communication to provide the optimum level of service in respect of investigations into all aspects of deaths in custody;
    • implement a national governance structure to promote and enhance the quality of investigation into death in custody through regular engagement, communication and sharing of best practice amongst key agencies;
    • ensure that relevant key recommendations from the ‘Independent Review of Response to Deaths in Prison Custody’ are successfully implemented in operational practice by respective organisations across Scotland;
    • consider and maximise joint training opportunities to raise awareness in relation to the requirements of death investigations and in particular obligations in terms of Article 2 ECHR.

Crown Office and Procurator Fiscal Service:

  • COPFS have established a Custody Deaths Unit, bringing together the specialisms from across the death investigation teams of Scottish Fatalities Investigation Unit and the Health and Safety Investigation Team. The establishment of a dedicated unit aims to support improvements in the quality and effectiveness of such investigations, prosecutions and FAIs and consistency of process throughout the country. All death in custody investigation are now the subject of regular senior management oversight as part of a process of Case Management Panels.
  • More efficient scheduling of FAI is supported by a system of regular liaison with the Scottish Courts and Tribunals Service, as part of which details of forthcoming Inquiries are provided to Sheriffs Principal.
  • A Death Investigation Improvement Programme has been established to take forward measures to improve the service provided to bereaved relatives and deliver increased efficiencies in the investigation of deaths. COPFS have enhanced the information provided on their external website to include a fuller description of the death investigation system. This includes information about the potential stages of a death investigation including the report of a death, limited investigations, full investigations, FAI, and determination.
  • COPFS undertook a small initial survey of a number of bereaved relatives and work is now underway to form a Lived Experience Advisory Panel, to provide COPFS with an important source of feedback and advice to help to shape improvements to the death investigation process in Scotland to ensure that investigations are thorough, occur in a reasonable timescale and have bereaved relatives at their heart.
  • COPFS have established a Service Improvement Programme, one of the aims of which is to provide a consistently high-quality standard of service, designed to meet the diverse needs to the public we serve. A key part of that programme will be introducing the measures that support trauma informed practice across the organisation.


  • SPS have piloted and now embedded a Harm Reduction Officer role across establishments with a remit for Support & Wellbeing. SPS have recruited 12 posts across the SPS run prison estate. These posts are additional to the existing Suicide Prevention roles already in place. The key areas of focus are:
    • Talk to Me & Self-Harm – to pro-actively champion best practice in case management and care planning for those deemed to be at risk; auditing and providing secondary assurance to senior management;
    • Support for local processes and compliance in relation to alcohol and drug use, including prescribed medication e.g. MORS;
    • Support for Recovery related activities and interventions – coordinating services; liaising with staff and internal and external partners;
    • Supporting the development of holistic care plans to support people in custody who are vulnerable taking into consideration causal factors such as bereavement, trauma, abuse, Adverse Childhood Experiences and disabilities.
  • These officers will play a critical role within the establishment concerned with monitoring and supporting staff to manage and care for those at risk of self-harm or suicide, those involved in alcohol and drug use or any persons of concern.



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