Ministerial Accountability Board: progress report - December 2025

10. Annex 1: Full Descriptions for Recommendations and Actions

FAI into the deaths of Katie Allan and William Lindsay (Brown)

Recommendation 1: Double bunk beds should be removed from all cells in any wing or hall within Polmont in which young prisoners are accommodated. SPS must take all necessary measures to ensure that no young prisoner is in future accommodated on a single occupancy basis in a cell in which there is a double bunk bed.

Recommendation 2: All door stops of the type identified in the book of photographs which forms Crown Production 92 (photographs 95 - 112), and which are of the same or equivalent design as the door stop used as a ligature anchor point by Katie, should be removed from all cells in Polmont and replaced with sloping door stops (such as that identified in the photograph in SPS Production 22/2), or an equivalent anti-ligature design.

Recommendation 3a: SPS should take steps to make standard cells at Polmont safer by identifying and removing, as far as reasonably practicable, ligature anchor points present in such cells. In that regard it should: Develop a standardised toolkit for auditing cells for the presence of ligature anchor points. This toolkit should, in particular, (i) identify both obvious and potential ligature anchor points; (ii) specify whether such points are inherent to the design of fixtures or fittings within the cell, or due to modification of, or damage to, such fixtures and fittings; (iii) provide a system of grading the level of risk in relation to each identified ligature anchor point (for example, by reference to the ease/level of ingenuity required to use it for self-ligature), and so provide a system of grading the level of ligature anchor point risk in relation to the cell as a whole.

Recommendation 3b: Use the foregoing toolkit to conduct an audit of potential anchor ligature points within all standard cells. This should result in the production of a report detailing all obvious and potential ligature anchor points within each cell, identifying whether they are inherent to the fixtures and fittings within the cell or are due to modification or disrepair, and provide a grading of the risk for each identified ligature anchor point and for the cell as a whole.

Recommendation 3c(i): In the light of the foregoing audit: As regards any ligature anchor points arising from damage to or modification of fixtures or fittings, (a) repair or replace same so as to remove or at least reduce the risk of ligature arising therefrom as soon as practicable; and thereafter (b) institute a policy of regular ongoing cell audit using the said toolkit so as to promptly identify and repair 12 or replace any further damage or modifications which have created further ligature anchor points.

Recommendation 3c(ii): As regards any ligature anchor points arising from the inherent nature of fixtures or fittings, (a) develop and publish a plan for their phased removal, replacement or modification, again so as to remove or at least reduce the risk of ligature arising therefrom; (b) specify a timeframe over which this plan is to be implemented having due regard to available resources; (c) commence implementation, for example, beginning with removal, replacement or modification of those fixtures and fittings graded as presenting the highest level of risk pursuant to the said toolkit; and (d) publish annual reports of progress in implementation of the said plan.

Recommendation 3d: Ensure that proposed fittings and fixtures in any new build or refurbished cells are audited using the said toolkit at the planning stage, and that any fittings or fixtures graded as presenting an inherent and significant risk of being used as ligature anchor points are not included within such cells when built or refurbished.

Recommendation 4: SPS should actively pilot and review use of in cell “signs of life” suicide prevention/ monitoring technology in Polmont. SPS should not confine this pilot and review to Safer Cells but should also consider its use in standard cells. SPS should report the findings of this pilot and review, and any recommendations 13 arising therefrom, to Scottish Ministers, within 12 months of the date of publication of this determination.

Recommendation 5: SPS should review and revise its policy regarding permitting young prisoners to routinely have possession of items which are readily capable of being used as ligatures without ingenuity or adaptation, in particular belts and dressing gown cords. The new policy should contain a presumption, as regards young prisoners in Polmont, that they are not permitted to have possession of such items. That presumption should only be overcome in limited circumstances, for example where a healthcare professional has certified in writing that the prisoner is not at risk of suicide and that there is therapeutic reason for permitting them to have use of such items. The Prisons and Young Offenders Institution (Scotland) Rules 2011, SSI 2011/331 (as amended) (“the Prison Rules”) should be amended accordingly.

Recommendation 6: SPS should undertake or commission a research project in relation to the availability and cost of alternative bedding materials for use in cells by young prisoners in Polmont. This should determine whether there are bedding materials available which, even if not certified as anti-ligature and inappropriate for use in standard cells (such as Crown Production 38) are nevertheless rip-resistant, to the extent that they are significantly less amenable to being cut or torn by a prisoner so as to form a ligature than are the bedding materials currently in use. SPS should publish the findings of this research project, and review its choice of bedding materials in standard cells at Polmont in the light of it.

Recommendation 7: The Scottish Ministers (“SM”) should put in place a system to ensure that all written information and documentation available to a court at time of remanding a young person, or sentencing them to custody, is passed to SPS with that young person on admission, whether physically or electronically, such that it can be considered when carrying out the RRA on that person. This should include, in particular, any written information or documents provided to the court by the young person or their representative, by social work or third sector agencies (including any criminal justice social work report (“CJSWR”)), and by health care services (including any mental health assessments carried out relative to the person’s fitness to appear in court).

Recommendation 8: SPS should introduce a secure electronic portal whereby social work, medical staff and third sector organisations can provide information relevant to a prisoner’s suicide risk directly to Polmont, and a system whereby any such information received will be immediately drawn to the attention of the first line manager (“FLM”) or nightshift manager of the hall where the prisoner is located, and recorded in a form which is readily accessible by SPS staff having contact with the prisoner.

Recommendation 9: SPS should provide a dedicated 24 hour telephone number by which family members can call into Polmont in order to notify a concern relevant to suicide risk which they may have in relation to a prisoner. This phone number should be readily accessible on the SPS website, along with guidance as to its purpose and use. Where such a concern is received, an electronic concern form should be completed immediately, sent to the FLM or nightshift manager of the hall where the prisoner is located, and recorded in a form which is readily accessible by SPS staff having contact with the prisoner.

Recommendation 10: SPS should introduce a system so as to ensure, except where there is an over-riding requirement in relation to prison security in a particular case, that where intelligence information is received suggesting that a young prisoner has been or is being bullied it (or at least the gist of it) is promptly and proactively shared with the FLM of the hall in which the prisoner is located, and with SPS staff having contact with them.

Recommendation 11: SPS and the FVHB should review their guidance in relation to sharing of information in relation to young prisoners in Polmont, and training in relation thereto, so as to ensure that both prison officers and health care staff are aware of all relevant issues which may affect a prisoner’s risk of suicide when assessing or reviewing his or her case.

Recommendation 12: FVHB should implement a system for ensuring that referrals received by the mental health team in Polmont are immediately passed to and reviewed by a mental health nurse and, where necessary, acted on without delay. Written instruction and guidance for relevant staff should be produced, and if necessary, training given thereon.

Recommendation 13: FVHB should provide further training to staff working within Polmont on the importance of accurate record keeping, with particular reference to the VISION system.

Recommendation 14(i): TTM should be revised as follows: TTM guidance should be amended to emphasise the increased risk of suicide (a) within a prisoner’s first 72 hours in custody and (b) during the more restrictive regime in operation at weekends. TTM should provide as a default, and in the absence of exceptional circumstances to the contrary, that all young prisoners should be made subject to TTM for a minimum of 72 hours after admission to Polmont, and not removed from TTM thereafter until and unless a case conference has so decided.

Recommendation 14(ii): All TTM risk assessment forms should be amended so as to contain a guided process for the assessor. This should include specific prompts, checklists, and questions to be answered and recorded, so as to better enable (i) the identification, assessment and recording of the prisoner’s suicide risk and protective factors at the time of assessment; and (ii) ongoing assessment in the light of any changes in any of those factors thereafter.

Recommendation 14(iii): Where a prisoner is assessed to be at risk of suicide, TTM initiation forms should be amended as to contain a guided process for the assessor in relation to care planning for a prisoner being made subject to TTM. This should include specific prompts, checklists, and questions to be answered and recorded, so as to better enable the initiating member of staff to grade the level of risk presented and so put in place protective measures for the prisoner which are sufficient and proportionate to it.

Recommendation 14(iv): TTM should contain specific guidance to prison staff in relation to obtaining background information relative to a prisoner’s suicide risk on admission, with express reference to the particular types of information which should be sought, when it is appropriate to obtain them, the process to be followed, and the person or persons who are responsible for doing so. In particular TTM should require staff to try to obtain background information relevant to suicide risk from the prisoner’s family, and from relevant health and social care agencies, (i) where the prisoner is young, (ii) it is their first time in prison, and/or (iii) there is evidence which may suggest a history of self-harm or suicide attempts. In such circumstances, and pending receipt of such information, the default position should be that the prisoner is made - or should continue to be - subject to TTM.

Recommendation 14(v): TTM guidance as regards risk assessment should be amended so as to better emphasise the importance of reduction of the risk of self-ligature in the context of suicide prevention. All risk assessment forms should be amended to require the assessor to consider the cell environment in which the prisoner is (or is to be) accommodated, and to assess the ligature anchor point risk within that particular cell as part of the overall risk assessment.

Recommendation 14(vi): TTM guidance as regards ongoing risk assessment should be amended so as to better emphasise (i) the importance of obtaining background information in relation to a prisoner, (ii) identifying dynamic risk and protective factors in relation to the particular prisoner, and (iii) that a prisoner’s self-report and non-verbal presentation in relation to a risk of suicide should not be taken as determinative, but must be considered in the light of such information. Where a prisoner is observed to be in distress such as should trigger the completion of a concern form, guidance should place a requirement on the officer concerned to review all TTM documentation in relation to the prisoner.

Recommendation 14(vii): In addition to the present system of suicide risk assessment based on RRAs and reactive day to day assessment by prison officers, TTM should include periodic proactive reviews and evaluations of a prisoner’s suicide risk and protective factors in the light of all available information. This should include review of prisoners who are not currently subject to TTM, and be at such frequency as may be determined on a case by case basis.

Recommendation 14(viii): SPS should develop a new system of recording issues of concern which relate to a prisoner’s suicide risk under TTM, so as to ensure that all relevant information in relation to such a risk is recorded in writing, collated in a single place, and is available to be periodically reviewed and assessed. Pending development of a new system of recording issues of concern, SPS should issue further guidance and provide specific training so as to clarify when a concern form should be completed by prison staff and its importance and purpose for TTM. This should emphasise: (i) that concern forms should be used where prison staff have witnessed a prisoner in distress, and are not only for use by external agencies or staff without regular access to prisoners; (ii) that a concern form should be completed even where it is not thought that the prisoner is at risk of suicide; and (iii) the importance of accurate and timeous record keeping in relation to concerns relevant to ongoing assessment of suicide risk.

Recommendation 14(ix): SPS should develop a system of electronic recording for all TTM documentation, that is, relating to a prisoner’s suicide risk assessment, recorded concerns and reviews, so as to ensure that all such documentation is not lost or mislaid, and is in any event readily accessible to frontline SPS staff.

Recommendation 14(x): A transitional care plan should continue to be mandatory for all young people removed from TTM, so as to ensure appropriate supports and follow-up checks are in place, and that their cell environment is appropriate in relation to potential ligature anchor points. Specific guidance and training should be provided on the options available to staff when compiling a transitional care plan for a young prisoner, including referrals to the FVHB mental health team, other agency referrals, counselling/other supports, or chaplaincy visits. This guidance and training should emphasise the prevalence of suicide by persons who have previously been subject to TTM.

Recommendation 14(xi): TTM refresher training should be provided to all staff at a significantly greater frequency and/or duration than 2 hours every 3 years, the precise amount to be determined by the current TTM review. Training should place particular focus on ligature anchor point and ligature item risks, the importance of accurate record keeping, the importance of obtaining information from external agencies, how to properly conduct a case conference, the use of concern forms, and any changes implemented as a result of the ongoing TTM review and this inquiry.

Recommendation 15: Where a prisoner has died by suicide, the DIPLAR process must consider, and if so advised make recommendations, in relation to the safety of their physical environment with Polmont and the means by which they were able to complete suicide. Where suicide has been by self-ligature, the DIPLAR process must consider the ligature anchor point risk of the cell or other place in which the death by suicide took place, and the nature and availability of the item used as a ligature.

Cabinet Secretary for Justice and Home Affairs additional commitments

Action 1: Death in Prison Learning and Audit Reviews (DIPLAR): All DIPLAR reviews should have an independent chair.

Action 2: Legal aid will be made free and non-means tested for families involved in Fatal Accident Inquiries related to deaths in custody. Primary legislation will bring this forward at the earliest opportunity.

Action 3: A focused, independent review of the FAI system will be conducted to improve its efficiency, effectiveness, and trauma-informed nature.

Action 4: Pursue the lifting of Crown Immunity with the UK Government.

Action 5: Independent national oversight mechanism to be introduced for deaths in custody.

Action 6: His Majesty’s Inspector of Prisons for Scotland will monitor and review the actions taken to ensure they are meeting the required outcome, reporting directly to CSJHA.

Action 7: Family Advocacy

FAI into the death of Jack Mckenzie

Recommendation 1: SPS should take steps to make standard cells at Polmont safer by identifying and removing, as far as reasonably practicable, ligature anchor points present in such cells. In that regard it should: a. Develop a standardised toolkit for auditing cells for the presence of ligature anchor points. This toolkit should, in particular, (i) identify both obvious and potential ligature anchor points; (ii) specify whether such points are inherent to the design of fixtures or fittings within the cell, or due to modification of, or damage to, such fixtures and fittings; (iii) provide a system of grading the level of risk in relation to each identified ligature anchor point (for example, by reference to the ease/level of ingenuity required to use it for self-ligature), and so provide a system of grading the level of ligature anchor point risk in relation to the cell as a whole; b. Use the foregoing toolkit to conduct an audit of potential anchor ligature points within all standard cells. This should result in the production of a report detailing all obvious and potential ligature anchor points within each cell, identifying whether they are inherent to the fixtures and fittings within the cell or are due to modification or disrepair, and provide a grading of the risk for each identified ligature anchor point and for the cell as a whole; c. In the light of the foregoing audit: i. As regards any ligature anchor points arising from damage to or modification of fixtures or fittings, (a) repair or replace same so as to remove or at least reduce the risk of ligature arising therefrom as soon as practicable; and thereafter (b) institute a policy of regular ongoing cell audit using the said toolkit so as to promptly identify and repair or replace any further damage or modifications which have created further ligature anchor points; ii. As regards any ligature anchor points arising from the inherent nature of fixtures or fittings, (a) develop and publish a plan for their phased removal, replacement or modification, again so as to remove or at least reduce the risk of ligature arising therefrom; (b) specify a timeframe over which this plan is to be implemented having due regard to available resources; (c) commence implementation, for example, beginning with removal, replacement or modification of those fixtures and fittings graded as presenting the highest level of risk pursuant to the said toolkit; and (d) publish annual reports of progress in implementation of the said plan; (d). Ensure that proposed fittings and fixtures in any new build or refurbished cells are audited using the said toolkit at the planning stage, and that any fittings or fixtures graded as presenting an inherent and significant risk of being used as ligature anchor points are not included within such cells when built or refurbished.

Recommendation 2: All cell toilet cubicle doors of the type identified in the book of photographs which forms Crown Production 16 (photographs 22, 24, 30 - 35), and which are of the same or equivalent design as the door used as a ligature anchor point by Jack, should be removed from standard cells occupied by young prisoners in Polmont and either replaced with doors of an anti-ligature design, or modified so as to materially reduce the ligature anchor point risk which they present.

Recommendation 3: Where a prisoner has died by suicide, the DIPLAR process must consider, and if so advised make recommendations, in relation to the safety of their physical environment within Polmont and the means by which they were able to complete suicide. Where suicide has been by self-ligature, the DIPLAR process must consider the ligature anchor point risk of the cell or other place in which the death by suicide took place, and the nature and availability of the item used as a ligature.

Recommendation 4: When a chronic or habitually drug using prisoner is removed from MORS they should be the subject of a suicide risk assessment under TTM. That assessment should involve a review of any previous TTM and MORS records and follow a standardised, approved process. The outcome of the assessment should be recorded in a prescribed form and stored in an accessible format. TTM and MORS should be amended accordingly.

Recommendation 5: TTM Guidance and training materials should be amended to make express reference to, and greater emphasise, the heightened risk of suicide by a young prisoner who abuses drugs whilst in Polmont. In particular these materials should be amended so as to direct staff of the need to take account of chronic or habitual drug use by a young prisoner in assessment of their suicide risk.

Recommendation 6: A visual hatch check, around one hour before the end of the night shift, should be reintroduced at Polmont to seek to ensure that all young prisoners are safe and well within their cells at this time.

Recommendation 7: SPS should review the instructions given to staff at Polmont regarding active patrolling of residential halls during patrol and night shifts. In the context of this review SPS should seek to identify ways to better reduce, at night, abusive and bullying verbal behaviour, drug dealing, and to respond to physical disturbances by prisoners within their cells. This review should also consider the adequacy of present staffing levels for this purpose. It should be completed within 6 months of the date of this determination, and a written report made to Scottish Ministers.