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

Appendix A – Background and Terms of Reference

Katie Allan and William Lindsay

Katie Allan and William Lindsay were both found dead in their cells at Polmont Young Offenders Institution in 2018. Katie died on 4 June and William died on 7 October. Both had died by suicide.

The joint FAI into Katie and William’s deaths by Sheriff Simon Collins KC was published on 17 January 2025^[13]. Sheriff Collins made a number of findings. He found that there were reasonable precautions which, had they been taken, both deaths might realistically have been avoided. He also said that there were systemic failures contributing to the deaths and that there were other facts relevant to the deaths which he formally recorded.

The Scottish Government accepted Sheriff Collins’ findings and the Cabinet Secretary for Justice and Home Affairs announced this independent review to consider the FAI system in Parliament on 23 January 2025, shortly after Katie and William’s FAI was published.

Terms of Reference

The Terms of Reference (TOR) for this Review were a matter for Scottish Ministers and can be found on the Review website^[14]. Briefly, I was asked to conduct a review which considered the FAI system and made detailed and actionable recommendations which focus on improving the efficiency, effectiveness and trauma-informed nature of FAIs into deaths in prison custody or police custody.

The Review was also asked to identify the specific barriers that families face in engaging with the process and the timescales involved, identifying any improvements that can be made on both fronts.

It is important to note that the TOR for this Review asked me to consider the FAI process relating to deaths in custody and not the issue of deaths in custody itself. Much work is ongoing around this and related issues across the Scottish public sector and I did not intend to examine or provide recommendations on the specific, important issue of deaths in custody. However, the very nature of people dying in state custody means that the key matters and issues are interlinked and it is impossible to look at one aspect of this process solely in isolation. I have heard directly from families that, if somebody they love dies in custody, it does not always matter to them the technical point at which an FAI takes over from initial or other investigations. They simply want to know what happened to them and, if it can be stopped from happening again.

Therefore, whilst my recommendations focus largely on the FAI process, I have considered and provided recommendations on death in custody investigation for Scottish Ministers consideration.

Death in Custody FAIs

Given my intention to produce a relatively short and focussed report, I do not intend to narrate the legislative basis or history of FAIs in Scotland at length or describe the circumstances in which they may be carried out outwith deaths in prison or police custody, but for the sake of clarity I have included some background.

FAIs are currently held in accordance with the Inquiries into Fatal Accidents and Sudden Deaths etc (Scotland) Act 2016^[15] (the 2016 Act). Section 2 of the 2016 Act sets out the circumstances in which an FAI must be held. These are where a death occurs in Scotland as a result of a work-related accident or where the deceased was in legal custody at the time of their death. Such inquiries are referred to as ‘mandatory inquiries’.

An FAI is a public hearing to establish what happened and prevent future deaths from happening in similar circumstances. An FAI can take place in a court, another public building or online. They are carried out in the public interest, that is to say that they are not carried out for the benefit of any individual party involved, but in order to benefit society as a whole.

In addition to Sheriffs Principal and Sheriffs, Summary Sheriffs can also preside over FAIs. However, in this report I have referred to Sheriffs only for readability.

Death investigations in Scotland are conducted by COPFS on behalf of the Lord Advocate, supported by reporting agencies such as Police Scotland or the Police Investigations and Review Commissioner. COPFS investigates all sudden, suspicious, accidental and unexplained deaths. The Lord Advocate can decide not to hold a mandatory FAI, if satisfied that the circumstances of the death have been sufficiently established during the course of other proceedings (such as criminal proceedings or a public inquiry).

Article 2 of the ECHR, the right to life, requires the state to carry out a thorough, independent and effective investigation into a death, particularly where the state was involved in the person’s care (such as when the person is in custody). Scotland’s FAIs are part of the statutory landscape that is in place to comply with this requirement.

I also consider it helpful to provide an overview of the general process when a death happens in both prison and police custody. I recognise that the operational procedures in place for each of these are detailed. However, I have summarised some of the key actions only briefly.

In relation to deaths in prison custody, the SPS described these to me in three incident management stages – Initial, Development and Closure. Steps taken in the initial stage include requesting the immediate presence of a nurse, instructing staff to call an ambulance and attempt resuscitation if possible, sealing off immediate area, starting an incident log and reporting to Duty Manager or Head of Operations immediately. If death is confirmed, the area is sealed off until Police Scotland (who are contacted immediately along with the Governor and SPS headquarters) arrive.

The development stage of a death in prison custody includes Police Scotland informing the next of kin, contact with the family being made by a member of the prison Senior Management Team, informing the Procurator Fiscal, His Majesty’s Inspectorate of Prisons, the Registrar and Chaplain. The circumstances of the death are investigated by Police Scotland, with statements taken by them from witnesses, and the Police and SPS consulting with regards to evidence gathering requirements.

In the closure stage of a death in prison custody, after care and support is provided as required for all involved, a stable return to prison regime is agreed, an incident report is collated and sent to SPS Headquarters. A Death in Custody File^[16] is also completed.

I also heard how DIPLARs and SAERs are considered in FAI investigations.

A DIPLAR is an internal SPS process to support the SPS to independently review all deaths in prison custody and to provide a system for recording learning and follow up actions. Following a death in prison custody, the local DIPLAR Co-ordinator is expected to arrange the DIPLAR meeting within 10 weeks of a death and prepare a draft report in advance of the meeting. Following the DIPLAR meeting, the DIPLAR report should be prepared within two weeks and then reviewed by the SPS HQ Health representative. The final report should be approved within ten weeks of the DIPLAR meeting and shared with the SPS Legal Services and COPFS.

SAERs are an internal NHS process carried out for any event that did cause, or could have caused, harm to a patient. An SAER is carried out by a ‘lead reviewer’ who will generally be a senior member of staff, not previously involved with the patient or the service delivering their care or treatment. The lead reviewer chairs any necessary meetings and write the SAER report. My understanding is that SAERs should also be completed within a matter of months.

Investigations in relation to deaths in police custody in Scotland are not led by Police Scotland. These deaths are investigated, on the instruction of COPFS, by the PIRC. This is an independent body which investigates incidents involving policing bodies in Scotland and reviews complaint handling by them.

There are relatively few deaths in custody referred to the PIRC, with only 5 referrals made from financial years 2023/24 to 2025/26 (to the date of the PIRC submitting evidence to this Review).

In relation to deaths in police custody, a memorandum of understanding is in place between the PIRC, Police Scotland and the SPA^[17]. Briefly, after a death in police custody, Police Scotland will notify the PIRC and COPFS. COPFS will consider the circumstances of the death and determine the mode of investigation. In cases relating to deaths in police custody, the PIRC will then assume primacy over the scene and the investigation