Understanding and Preventing Deaths Working Group minutes: July 2022

Minutes from the meeting of the group on 28 July 2022

Attendees and apologies

  • Gillian Imery, External Chair, Oversight of Recommendations of Independent Review into Response to Deaths in Prison Custody
  • Rachel Wallace, Prisoner Healthcare Team, Scottish Government
  • Stuart Henderson, Drugs Policy Team, Scottish Government
  • Dr Craig Sayers, Clinical Lead, National Prison Care Network, NHS
  • Neil Gentleman, Inspector, Care Inspectorate
  • Catherine Haley, Senior Inspector, Healthcare Improvement Scotland
  • Katie Godfrey, Mental Health in Prisons Lead, Scottish Government
  • Fiona Wilson, Mental Health and Suicide Prevention, Scottish Government
  • Eilidh Cunningham, Assistant Programme Manager, National Prison Care Network, NHS
  • Laura Begg, Community Justice, Scottish Government


  • Wendy Sinclair-Gieben, HMIPS
  • Henry Acres, Drugs Policy Team, Scottish Government
  • Nicola McAndrew, Prisoner Healthcare Team, Scottish Government
  • Jane Kelly, Care Inspectorate

Items and actions

Welcome and introductions

Gillian Imery introduced herself and Laura Begg to the group and explained their respective roles in relation to the oversight of the implementation of the recommendations of the Independent Review of the Response to Deaths in Prison Custody. Gillian Imery explained she had set up a Deaths in Prison Custody Action Group (DiPCAG) with representatives from the agencies involved in implementation of the recommendations to oversee and push forward the changes required. The governance structure is that the DiPCAG is the oversight group that any other working groups, including this one would report to. Group also informed that Gillian Imery had established a family reference group which is a forum where those progressing the recommendations could come to and discuss options, suggestions for progressing recommendations and seek the views of families to gain the benefit of their experience.

Scope of the working group/terms of reference

This working group has been established to progress recommendations 1.1 and 3.4 that focus on understanding and preventing deaths. A number of oversight agencies are named in the recommendation that should work together with families to create a framework with the aim of preventing deaths in prisons. Clear link between the two recommendations, seems logical need to understand better why people die in prison to create an effective framework aimed at reducing those deaths

Group were invited to comment on whether any other agencies should be represented on the working group. Apologies had been received from HMIPS, PHS and Drugs Death Taskforce.

A number of members of the group queried whether the SPS should invited to join the group. Chair to consider.

Group were invited to comment on what should be included within the terms of reference for the group. Discussion amongst group that the recommendations were framed very broadly. Gillian Imery clarified that she felt that whilst the recommendation said “…deaths in custody”, her view was the scope of the group was in respect of prison custody and not other custody settings, as that was too wide and the remit of the review was prison custody. This was agreed by the group.

Access to data and analysis of causes of deaths in prisons

Gillian Imery explained that the authors of the Independent Review highlighted lack of good corporate data in relation to deaths in prisons. The SPS on their website publish some data. Until recently cause of death wasn’t published until conclusion of FAI which could mean a delay of number of years after death. Reduction in delay as SPS now publish cause of death as it is recorded on death certificate. However felt very technical language, doesn’t look at underlying contributory causes and any potentially preventative action. 

Group asked whether there was any awareness of any agencies/oversight bodies who currently analyse any of the data relating to deaths in prisons.

Cath Haley advised that she was aware that Healthcare Improvement Scotland (HIS) had an adverse events reporting system that covered suicides and near misses. She undertook to speak to the lead to ascertain what information was collected and how that may assist the work of the group.

Craig Sayers commented that it was important to be sure that all deaths were captured and to do so, group needed to know how many of each type of death had happened and the reason for that death. Need to be able to breakdown the reasons that contribute to deaths to in turn know where to focus efforts that could potentially prevent future deaths.

Neil Gentleman commented that HMIPS may be provided with more background information about deaths in their pre-inspection information.

Gillian Imery advised the group there is a tendency to treat each death as a stand alone set of circumstances and the recommendation wants to step that up a level to look at more contributory factors. There has been a steady increase in the number of deaths in prisons and last year involved a significant jump in numbers.

Stuart Henderson cautioned that the prison population was relatively small and that drawing inferences because of the relatively small numbers is difficult. It may be difficult in trying to interpret trends particular as need some context such as common health challenges facing those most likely to be imprisoned.

Monitoring standards of care in prisons and measuring improvements

Gillian Imery advised the group that she was aware of HMIPS Standard 9: Health and Wellbeing – which relates to assessment of healthcare in prisons as part of the joint inspection of prisons along with HIS.

Neil Gentleman advised that the Care Inspectorate also looks at transitions back to the community. Standard 6: Education, looks at communications with families and that is something that they would want to also assess.

Group asked whether they had any awareness of any other ways in which standards of care in prisons are measured, particularly in the years in between HMIPS Inspections.

Cath Haley advised the group that she was aware that prisons completed a self-evaluation and submitted evidence against the standards. No follow up on a yearly basis. Had been considered but put on hold due to covid.

Craig Sayers advised that he was not aware of any other data relating to assessment of care in prisons. He had an awareness of some aspects of healthcare that NHS were not doing particular well with. It was unrealistic for the National Prison Care Network to tackle all of them and they were focusing on picking particular big topics. For example, wanted to do electronic monitoring of prescriptions. Very workforce dependent and currently running less 40% capacity. If statistics were available about certain chronic diseases for example, that may help them get more resources to tackle that.

There was a discussion that there was a sense of frustration about the role of social workers in prisons, beyond statutory risk assessment activity.

Creation of framework for preventing deaths

Group were asked whether they had any suggestions for the style and form that the framework should.

Craig Sayers raised the point that the population of prisons has changed and there is a need to identify what the problems are. There is a need to get more data on themes of deaths. Also might find that some work has been done in addressing some areas of concern and don’t want to duplicate that.

Cath Haley advised the group that there was a lot of work going on in relation to Medication Assisted Treatment (MAT) standards nationally.

Fiona Wilson advised the group that there is a new suicide prevention strategy with an action plan that includes one for criminal justice and prison. Currently out for consultation and hoping to be published in September.

The group agreed that there was a need to get as much information as possible about ongoing work and bring it together. Also to build on current standards and a lot to learn from different frameworks and thematic inspections.

Gillian Imery asked the group to consider who was best placed to lead on this work required to create a new framework.

Engagement with families

Gillian Imery advised the group that she was very motivated to ensure that families should have a genuine role in making progress in these recommendations. Very encouraged that families want to be involved with family reference group. Some of those families had been part of the Independent Review whilst others had lost family members more recently and had faced the same challenges. Clear same sensitivities still persist. Recommendation is asking the group to work with families to implement. Group asked how they think families could best be involved.

Cath Haley raised the point that there may also be merit in engaging with prisoners as any framework will also impact on them.

Group agreed that they felt that they needed to have a clearer idea of what the framework might look like before asking families to become involved and that it would be invaluable to have the input of families.

Gillian Imery advised group that she was keen for the work of the group to be a co-production with the input of families.

Next steps

Gillian Imery reminded the group of the need to keep families front and centre working towards progress on the recommendations. The group were advised that the Chair has given a commitment to provide a public update on progress in November, a year following publication of the Independent Review.

Group agreed that the next steps for everyone was to consider their area of knowledge and expertise and bring back to the group work going on nationally that can feed into progress on the recommendations. Also to bring ideas about gaps in current ongoing work that group may need to look to address to progress recommendation. 

Another other business

No matters raised.


  • Laura Begg to circulate draft Terms of Reference to the group for comment
  • Cath Haley to speak to HIS lead on adverse events reporting in relation to suicides in prisons to ascertain what information was collected and how that may assist the work of the group
  • All to prioritise making enquiries within own organisation/policy areas to ascertain current/ongoing pieces of work that may be of relevance to the work of the group to aid mapping exercise of establishing current work that could potentially feed into framework. As much information as possible about this to be sent to Laura Begg by 12th August
  • All to consider who/which organisation most appropriate to Chair the working group
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