Deaths in custody - Independent Review of Fatal Accident Inquiries 2025: report

Conclusion

The key message I heard over the course of chairing this Review was that the FAI system relating to deaths in custody, as it stands, is not fit for purpose. I heard repeatedly how long FAIs take and, despite often the best efforts of everybody involved, that they are failing to achieve their key aims.

Not only this, the process as it stands is far too traumatising and difficult for families and loved ones of those who have lost their lives, as well as for staff in the organisations involved in police custody, Scottish prisons and prisoner care.

There must be a robust system to investigate deaths in custody settings. This system must get to the heart of what happened and show how to stop adverse and preventable events happening again. I have concluded that the FAI system can only do that if it becomes faster, more effective, and more transparent. It also appears to me that it is at its most effective when all those with an interest are engaged. Therefore, it also needs to be clearer and more compassionate for the families and loved ones of those who have died. It must be accessible and humane and all of this must happen at pace, with the truth at its heart.

I hope the recommendations in this report, when implemented, go some way to achieving this. However, the scale of the improvements needed should not be underestimated and changing many of the ways we think around deaths in custody FAIs will need a great deal of work from organisations across the FAI landscape. I implore government and organisations to commit to these changes, for a better and fairer system.

I am aware that the recommendations in this review are not radical in the sense of proposing a fundamental reform of the structures of the FAI process. I am however asking the organisations involved to substantially reform and reimagine the way in which they deliver the functions that contribute to that process. In particular, they need to work at a rapid pace and place the experience of bereaved families at the centre of what they do.

I would like to take this final opportunity to, once again, pay tribute to and thank the families of those who have died in prison for sharing their experiences with me. Your support and honesty shaped this Review and I have been humbled by your openness.