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

Appendix B – Methodology

I was appointed in May 2025 and the Cabinet Secretary asked me to report by the end of the year. This Review was, therefore, carried out quickly. I had to gather information rapidly from a variety of people and organisations and I used a number of different approaches to do this.

There is a huge amount of published material, in the form of reports, articles and previous reviews, relating to deaths in custody and FAIs in Scotland. Reading this material was extremely useful in understanding the FAI landscape as it stands in Scotland and providing me with an overview of some of the current key issues.

I wrote to, and held a number of meetings with, key organisations in the FAI sphere. These included SPS, COPFS, Police Scotland and the PIRC. These organisations kindly provided written evidence in advance of our meetings, answering specific questions I had also put to them in writing. This written evidence often formed the basis of our meetings and helped to focus our discussions.

I was also very grateful for the opportunity to hear from families of those who have died and their representatives. This included a meeting with the families of Katie Allan and William Lindsay. I attended a very helpful Family Listening Day, in which families shared their experiences of losing a loved one in custody in a space designed for them to do so, and a meeting of a group of families chaired by the head of the charity Families Outside. I found these both extremely moving and key to considering the specific issues this Review intended to address.

I met with a number of people whose work in the areas of death in custody and inquests into these deaths related to the remit of my Review. For example, I was very grateful to Deborah Coles and INQUEST for arranging a meeting with some members of the INQUEST lawyers group, which was invaluable in considering the coronial system in England and Wales. I also met with Dr Georgia Richards, founder of the Preventable Deaths Tracker, an evidence-based vigilance platform to learn lessons following death investigations, and Juliet Lyon, former Chair of the Independent Advisory Panel on Deaths in Custody.

Finally, during August and September 2025 I ran an online call for evidence where I hoped to hear from those with experience of the FAI system. I was particularly interested in hearing from individuals with direct experience (either personal or professional) of the FAI system, an interest in the FAI system or the experiences of those who interact with it (for example academic or research professionals). I also wanted to hear from individuals and organisations with knowledge of other systems that might offer ideas for improving our FAI system for deaths in custody. This attracted 24 responses. Of the 24 responses, six were submitted by individuals and 18 by organisations.

I am grateful for all views which have been shared with me over the course of my Review. I am especially grateful to those who took time to meet me in person to share their views, experience and expertise, and the frankness with which they did so. A summary of the evidence gathered is shown at Appendix C.