Understanding and Preventing Deaths Working Group minutes: December 2022

Minutes from the meeting of the group on 7 December 2022

Attendees and apologies

  • Gillian Imery, External Chair, Oversight of Recommendations of Independent Review into Response to Deaths in Prison Custody
  • Jane Kelly, Service Manager, Care Inspectorate
  • Karyn McCulskey, Chief Executive, Community Justice Scotland
  • Laura Hoskins, Head of Policy and Improvement, Community Justice Scotland
  • Dr Craig Sayers, Clinical Lead, National Prison Care Network, NHS
  • Moira Manson, Senior Inspector, Healthcare Improvement Scotland
  • Fiona Wilson, Mental Health and Suicide Prevention, Scottish Government
  • Eilidh Cunningham, Assistant Programme Manager, National Prison Care Network, NHS
  • Shirley Windsor, Organisational Lead Public Mental Health, Public Health Scotland
  • Sam Gluckstein, His Majesty’s Inspectorate of Prisons for Scotland
  • Amy Wilson, Head of Justice Analytical Service, Scottish Government
  • Suzy Calder, Head of Health, Scottish Prison Service
  • Nicola McAndrew, Prisoner Healthcare Team, Scottish Government
  • Laura Begg, Community Justice, Scottish Government


  • Wendy Sinclair-Gieben, HM Chief Inspector of Prisons
  • Catherine Haley, Senior Inspector, Healthcare Improvement Scotland
  • Henry Acres, Drugs Policy Team, Scottish Government
  • Jocelyn Hinds, Head of Data and Analysis, Scottish Prison Service

Items and actions


Gillian Imery thanked everyone for attending. The group were informed of some changes to the membership: Jane Kelly will attend on behalf of Care Inspectorate and Neil Gentleman will no longer be a member; Shirley Windsor will attend on behalf of Public Health Scotland (PHS) and Diane Stockton will no longer be a member. Moira Manson was welcomed to the meeting in place of Cath Haley for Healthcare Improvement Scotland (HIS), as was Sam Gluckstein in place of Wendy Sinclair-Gieben for HMIPS.

Some new additions to the group were also welcomed: Amy Wilson from Scottish Government's Justice Analytical Services (JAS) and Suzy Calder from SPS, who was attending in place of Jocelyn Hinds, SPS new Head of Data and Analysis.

Gillian Imery informed the group that Linda Allan had withdrawn from being a member of the group and co-Chair for personal reasons. Acknowledged that the input from families was invaluable and need to be respectful of the potential consequences for bereaved family members of being involved with this work. Gillian Imery to ask Linda Allan whether she has any suggested for how the group should engage differently with families.

Gillian Imery to ask Families Outside for advice on other potential ways of engaging with families which may not include them being members of a group.

Minutes of last meeting and actions

No comments were received on the minutes from the previous meeting on 28 September.

Actions from last meeting:

  • Linda Allan to draft a work plan to circulate to the group for comments

With Linda Allan withdrawing from the group this action hasn’t been completed. Included as an agenda item to discuss more fully.

  • Linda Allan to explore with potential academics possibility of being involved in a review of causes of deaths

Discussion did take place with some academics about the possibility of them being involved, however there would be an associated cost which there isn’t budget to cover. Gillian Imery advised group that since the last meeting pleased to say have been working with SPS, JAS and National Prison Care Network (NPrCN) on data and they’ve agreed to work with the group to carry out an analysis into causes of deaths in prisons. Included as an agenda item to discuss more fully. 

  • all to consider draft Terms of Reference and provide any comments

This will require further revision as the co-chair has withdrawn from the group.

  • Care Inspectorate representatives to provide information to the group about the Child Death Hub

Jane Kelly advised that the group that she was working on a paper which she hoped to be able to share with the group soon to allow consideration of whether there was any relevance to the work of the group that could be adapted for use.

  • Prisoner Healthcare Team to be asked to provide information to the group about the prisoner healthcare needs assessments and plan for implementation

This has been included as an agenda item for a fuller discussion. 

Discussion also took place around the need for a replacement Chair/Co-Chair for the group as Linda Allan has withdrawn from being involved. Gillian Imery commented she thought it is unlikely that there is another family member from the family reference group who will want to undertake this role. Looking for a member of the group to volunteer to undertake this role. Reminder that recommendation 1.1 is about national oversight bodies working together to develop a framework aimed at preventing deaths. Suggests that one of these bodies should be stepping forward to Chair the group. Plea from families to make the work of the group more tangible and need to think how we deliver something.

Action for all, particularly those named in oversight bodies in recommendation 1.1, to consider taking on role of Chair/Co-Chair to help drive forward work of group. 

Data on deaths in prisons – what analysis would be helpful to inform the work of the group?

Discussed at previous meetings about the lack of publicly available data or analysis of causes of deaths. Group needs to consider what information it would be helpful to analyse that may improve understanding of why deaths occur in prison.

Recent report published by Glasgow University, which Linda Allan was a co-author of, focused in particular on deaths in prisons by suicide and drug related and lack of findings in FAIs. Some of the keys findings of that report were:

  • shows there have been 121 deaths since the start of 2020, with suicide and drugs deaths on the rise
  • there have been 29 deaths by suicide and 25 from drugs since the start of 2020
  • the rate of suicide and drugs deaths in Scottish jails is significantly higher than in England, the report said
  • the prison service introduced its suicide prevention strategy called Talk To Me six years ago
  • the academics found that there had been a 42% increase in suicides since the strategy was introduced compared with the six previous years
  • Fatal Accident Inquiries into prison deaths took more than two years to complete and almost never made any recommendations or offered points of learning for the prison service

Since the last meeting, Gillian Imery and Laura Begg have been working with the NPrCN and SPS to start trying to undertake a review of causes of deaths in prisons. More recently also secured the support of Justice Analytical Services for this work. Circulated to the group were two initial draft reports created using publicly available data. Aware there are some anomalies/incomplete data in the documents and they have not been peer reviewed. Created as a starting point amongst the group to consider whether this type of analysis is helpful, what other data it would be helpful to look at as part of a review of causes of deaths and any other suggestions for how causes of deaths in prisons should be reviewed.

Karyn McCluskey commented that there were many gaps in the information and in particular should be some focus on precursors and a need to look at what can do to intervene. Offered to provide a list of suggestions for other information it would be helpful to consider.

Suzy Calder commented that document produced was very much an initial first draft. Know that there is an increase in the number of deaths and commented not directly comparable to data from England and Wales. Suggested looking at DIPLARs as this would give more access to qualitative data. Aware significant amount of information ingathered at a DIPLAR but not analysed in a way that enables to draw conclusions.

Shirley Windsor commented that it may be of relevance to consider Adverse Childhood Experience information.

Craig Sayers advised the group that the focus of the NPrCN had been on drugs deaths. 10 years ago they were rare in prisons but now more common.

Better understanding of causes of deaths could help NHS target certain areas with more resources, such as the management of certain chronic diseases. Commented that should also be consideration of a ‘good death’ in prison and understanding that some people want to die in prison as that is where they lived.

Eilidh Cunningham added that so far their analysis had tried to focus on the substances involved. Other factors that may be of relevance would be: whether they had any near misses or episodes on MORs; how long they had been in prison, whether they had a history of pre-existing substance misuse prior to entering prison.

The group were advised that the NPrCN were collating data on GeoAmey missing appointments for secondary medical care. There was no immediate solution for this and explanation provided was that it was a resourcing issue.

Sam Gluckstein commented that this issue had been raised with the Cabinet Secretary by HM Chief Inspector of Prisons. He was aware GeoAmey had been fined significantly for breach of contract but not seeing much evidence of improvement.

Amy Wilson commented on the contribution that JAS could potentially add. These were:

  • working with colleagues at the SPS and National Records of Scotland to source more relevant data, such as age standardisation and death records
  • pulling people together to peer review analysis work. Can provide leadership support to the SPS
  • consider data linkage, such as previous health records, health history/educational records, richer understanding of backgrounds
  • research background – happy to consider if can develop a research plan

Jane Kelly suggested that Criminal Justice Social Work records can be an important source of information.

A query was raised about whether systems were fit for producing statistics.

Amy Wilson advised that JAS produce longitudinal data based on the SPS prisoner records system, PR2. Suggested it may be best data to use.

All, to consider any gaps in the data contained within the draft reports circulated with the agenda and to suggest any further information it would be useful to obtain/analyse to better understand deaths in prisons.

Prisoner healthcare needs assessments

Nicola McAndrew explained that the four healthcare needs assessments reports, along with a synthesis report were published in September 2022. Had been a number of years since they were last done. Since they had been published, the prisoner healthcare team have undertaken a piece of work to assess the 67 recommendations to consider state of play/attitude towards each of them. Have been working alongside the SPS and NPrCN on this. Recently met with their Minister, want to make a governmental mission to improve healthcare in prisons. Need highest level of buy in to make improvements. Ministers meeting later in December to discuss individual interests and how they can drive change in this area. Without leadership hard for things to change. Stakeholders don’t want more groups to sit on to discuss cross-cutting issues.

Nicola McAndrew advised that the Health and Justice Collaboration Board are focusing on the national mission relating to drug deaths. Obvious link between the assessments and that mission.

Suzy Calder commented that there was a fairly complex landscape and a huge number of recommendations aimed at SPS and NHS. They are doing a piece of work to try to theme them, around 500 in total. Can be unmanageable.

Next steps – action plan and what are the deliverables for the group?

Discussion focused on taking a pragmatic approach to the recommendation. Comments from group that still don’t have a clear idea of what authors of the recommendations envisaged. Want to augment strategies/policies already being implemented. Group should focus on some avenues of work that can potentially prevent future deaths. Not fixed on the idea that a whole new document requires to be created. Sounds like all of the right people are engaged with the healthcare needs assessments. 

Suggested one potential avenue group should consider is enhancing scrutiny on what is being done to prevent deaths in prisons. Current monitoring and inspections take place every 4-5 years. Potentially could be more regular returns about information about healthcare in prisons. 

Moira Manson advised that she was involved with the review of both the SAER and DIPLAR process. HIS are working with the SPS on both. That work can potentially feed into deliverables for the group. Commented that felt patients and families can bring more to process. Also missing a wealth of information from near misses.

Advised that once standardisation work, along with a revised adverse events framework was in place, estimated to be 18 months, the HIS programme of work will move to scrutiny and assurances of adverse events processes, including learning and contributory factors.

Any other business



  • Gill Imery to discuss with Linda Allan any suggestions for how to engage with families differently to be mindful of potential impact on them of involvement with this work. Gill Imery also to explore with Families Outside alternative methods of engaging with families
  • Jane Kelly to share paper with group on Child Deaths Hub to allow consideration of whether model may be relevant to collection of information on deaths in prisons
  • all, particularly those named in oversight bodies in recommendation 1.1, to consider taking on role of Chair/Co-Chair to help drive forward work of group. To let Laura Begg know if you willing to undertake this role
  • all, to consider any gaps in the data contained within the draft reports circulated with the agenda and to suggest any further information it would be useful to obtain/analyse to better understand deaths in prisons. Response to this action point to be provided by 16th December
  • Amy Wilson, Jocelyn Hinds and Prison Care Network to work together with colleagues from NRS to source more relevant data re deaths
  • Amy Wilson to provide leadership/support to SPS in respect of analysis of data re deaths, including pulling together people to provide peer review of this work
  • Amy Wilson to consider ability of JAS to develop a research plan and undertake research to support work of group
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