Death in Prison Custody: action plan - updated July 2023

2. Progress on recommendations

2.1 Theme: Key Recommendation

Recommendation 1

Owner: Scottish Government

Progress made: The draft process has been agreed by the working group. The process will be piloted in two phases to test the workability of the process. A Memorandum of Understanding (MOU) and Information Sharing Agreements (ISA) require to be developed. The pilot evaluation is being considered.

Next key actions: Logistics of the pilot to be confirmed. The MOU and ISAs to be finalised. Guidance on anonymisation needs considered.

2.2 Key theme: Family contact with prison and involvement in care

Recommendation 1.1

Owner: Various – Healthcare Improvement Scotland (HIS), NHS boards, the Care Inspectorate, National Suicide Prevention Leadership Group, His Majesty’s Inspectorate for Prisons in Scotland (HMIPS) and Scottish Government

Progress made: Justice Analytical Specialists (JAS) will publish an initial report on deaths in prison between 2012-2022. SPS extracted information from 220 completed DIPLAR reviews. NHS established the prison GP forum and are collating quarterly data on the numbers of GEOAmey cancellations from prison to secondary care. A request was made that those who miss appointments due to transport cancellations be prioritised on waiting lists.

Next key actions: JAS to work with NRS to produce data to allow for comparisons with the general population and obtain information regarding causes of death pre-2019. SPS to analyse the data extracted from DIPLAR reviews to provide more qualitative data around causes of death. National Prison Care Network (NPrCN) to develop guidance on the clinical management of people suspected of intoxication.

Recommendation 1.2

Owner: NHS (to lead) and SPS

Progress made: NHS has an advanced draft of the Toolkit for staff provides information on the initial response following a death in prison; NHS input to reviews; training modules, webinars and resources; and training and support on engaging and communicating with bereaved families. NHS have developed resources to support staff attending FAIs, outlining what to expect and who will likely be involved.

Next key actions: The NHS draft Toolkit will be circulated with NHS Boards and wider partners for review and update accordingly.

Recommendation 1.3

Owner: SPS

Progress made: The Electronic Concern Form (ECF) will remain in place with existing partners. To better meet this recommendation, avoid undue stress and unnecessary delays and be more responsive to serious concerns, SPS plan to implement a specific ‘Raising a Concern’ 24-hour direct phone line. Concerns pertaining to healthcare would be communicated to NHS staff.

Next key actions: The ‘Raising a Concern’ booklet is being finalised and will be available via the SPS website and family centres. SPS to record the answer machine message to include the ‘raising a concern’ option by mid-July. Telephones will be distributed to all establishments. SPS to brief staff and draft standard operating procedures regarding call responses. Once implemented, audits will take place.

Recommendation 1.4

Owner: SPS (to lead) and NHS

The recommendation has been implemented.

2.3 Key Theme: Policies and processes after a death

Recommendation 2.1

Owner: NHS (to lead) and SPS

Progress made: Please see recommendation 1.2 for an update.

Recommendation 2.2

Owner: SPS

Progress made: The new ligature cutters are in every establishment and deployed for use. Staff briefings were completed on use and a training video has been produced and made available on the staff training platform. Guidance and processes for both sanitisation and re-sharpening were developed.

The recommendation has been implemented.

Recommendation 2.3

Owner: NHS (to lead) and SPS

Progress made: The confirmation of death training has been finalised; and should be accessible by the end of June 2023. Confirmation of death pocket cards have been received for distribution to nursing staff following the webinar. Standard Operating Procedures were developed to accompany the training webinar.

Next key actions: The guidance to support the training has been agreed and will be circulated once training module is available. NPrCN to refresh Induction Resources to incorporate Confirmation of Death training for new nurses. Distribute Confirmation of Death pocket cards to Prison health centres.

Recommendation 2.4

Owner: SPS

Progress made: The DIPLAR paperwork and guidance was consulted on including with the family reference group and updated accordingly. The process ensures the NHS involvement throughout. The new paperwork and guidance have been tested and initial feedback was provided.

Next key actions: The paperwork will be tested with a natural cause death, scheduled for July. Approval for implementation will be sought and implementation dates confirmed. A Governors and Management Action (GMA) notice will be drafted and circulated to all establishments. Reviews will take place after 6 months.

Recommendation 2.5

Owner: SPS, NHS and Scottish Government

Progress made: The DIPLAR Review will be consistently applied for all deaths in prison custody. Where this involves a child or young person, further scrutiny and assessment will be followed up. This has been added into the new DIPLAR process, template and guidance. Where the death of a child or young person occurs, their case manager is a core attendee for the DIPLAR.

Next key actions: Further work is required to describe the policies that apply and the assessment tools that would demonstrate SPS are effectively working in accordance with UNCRC. Formal connection to be established with SG dept responsible and key experts in NHS.

2.4 Key theme: Family contact and support following a death

Recommendation 3.1

Owner: SPS

The recommendation has been implemented.

Recommendation 3.2

Owner: SPS (to lead), NHS and the COPFS

Progress made: Work between COPFS and SPS progresses. Chaplaincy Team have supported sessions with Governors in Charge and Deputy Governors and on contacting families. NHS initiated discussions with NHS Education for Scotland on whether compassionate communication can be delivered to NHS prison staff.

Next key actions: Continued discussion between SPS and COPFS. Explore recording Chaplaincy Team sessions to allow ongoing engagement. SPS College to engage with NPrCN to consider potential to share in bespoke Compassionate Skills Training.

Recommendation 3.3

Owner: SPS and NHS

Progress made: The Family Support Booklet (FSB) has been reviewed, updated, distributed across establishments and made available online. The Booklet contains details on the DIPLAR process; contact details; links with the NHS; and available support. Families are provided the opportunity to raise questions with these being followed up post meeting.

The recommendation has been implemented.

Recommendation 3.4

Owner: SPS, NHS and Scottish Government

Progress made: Please see recommendation 1.1 for an update.

2.5 Key theme: Support for staff and other people held in prison after a death

Recommendation 4.1

Owner: NHS (to lead) and SPS

Progress made: Support packages and training for staff have been mapped and included in the Toolkit. Work to replace the Critical Incident Response and Support (CIRS) policy is underway. The interim Employee Assistance Programme (EAP) has been reviewed and a new package developed. Trauma Support Booklets have been developed for staff. A literature review has been undertaken on support options. Meetings occurred with other organisations to learn best practice. Trade Union partners were involved and had opportunity to consider the revised process.

Next key actions: Once finalised, the trauma informed practice tiered framework will require agreement and dissemination to NHS Boards. Consideration and further development of a national approach to supporting healthcare professionals in prisons is required. SPS to attend the Family Reference Group and provide an update on the work underway to support staff. SPS to develop a revised package to replace CIRS using best practice. Checks at DIPLAR meetings to ensure that staff have been offered support and that the EAP is providing positive outcomes.

Recommendation 4.2

Owner: NHS (to lead) and SPS

Progress made: Please see recommendation 4.1 for an update.

2.6 Key theme: SPS and NHS documentation concerning deaths

Recommendation 5.1

Owner: SPS (to lead) and NHS

Progress made: Please see recommendations 2.4 and 3.3 for updates.

Recommendation 5.2

Owner: SPS (to lead) and NHS

Progress made: Please see recommendations 2.4 and 3.3 for updates.

Recommendation 5.3

Owner: SPS

Progress made: Please see recommendation 2.4 for an update.

Recommendation 5.4

Owner: SPS

The recommendation has been implemented.