Death in Prison Custody: action plan - updated March 2024

2. Progress on recommendations

2.1 Theme: Key Recommendation

Recommendation 1 

Owner: Scottish Government 

Progress made: An initial desktop pilot exercise took place over two days in October 2023. Number of issues raised will feed into the evaluation process. An evaluation of the first pilot exercise is ongoing and will consider views of those involved. HMIPS have produced a final report which has been circulated to all organisations for feedback.

Next key actions: Second pilot exercise is scheduled for March 2024 and preparation work ongoing. Evaluation of that pilot exercise will be undertaken. The aim is to have the evaluation process for both pilot exercises to be completed by end of May for discussion about next steps.

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: SG Justice Analytical Services (JAS) are leading on a further report with data from National Records Scotland (NRS) which will include comparisons with trends in general population. Data sharing agreements are in place between JAS and NRS. NRS data has been received and JAS has recruited additional resource to focus on this work.

Next key actions: The next report will include age standardisation and use of the World Health Organisations definitions to make comparisons between the general population and the prison population. Next publication due to be published in the next few months and there should be an annual publication in future years.

Recommendation 1.2 

Owner: NHS (to lead) and SPS 

Progress made: Toolkit has been circulated to NHS Boards and to Health Board Chief Executives who have agreed to implementation. Implementation of the toolkit has also been included as an ask in the 2024/25 NHS Board Annual Delivery Plan. QI dashboard developed to monitor implementation on a quarterly basis.

Next key actions: National Prison Care Network (NPrCN) to ask Health Boards in April 2024 to collect usage for Jan-March 2024. Data collection will repeat on a quarterly basis. Toolkit will be reviewed in October 2024 and amended accordingly. The Toolkit will then be reviewed on an annual basis.

Recommendation 1.3 

Owner: SPS 

Progress made: All SPS establishments have dedicated phonelines for receiving calls of concern. Revised policy document and detailed guidance for staff has been issued. The phonelines went live on 1 February with establishments maintaining assurance logs of calls received and weekly call reports generated by the system to allow for auditing. All 'misuse of service' calls also recorded on logs. SPS HQ Health copied into all weekly reports and monitoring call data. Further work being done with SPS Comms to finalise promotional materials and website content. The new SPS website is currently scheduled to go live in February 2024. The Concern Phoneline is a prominent link on the home page of the new website, which contains a direct link to a list of phone numbers for each establishment. It is also accessible through the Families section, and in the News section.

Next key actions: SPS intend to create an additional family information booklet regarding raising concerns and this will be finalised along with further promotional material by April 2024.

This recommendation has now been implemented.

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 

The recommendation has been implemented. 

Recommendation 2.3 

Owner: NHS (to lead) and SPS 

Progress made: Uptake data request circulated January 2024 and data was received from 12 establishments, average update of 84% with 160 nurses completed the training. Those who have not yet completed are either new in post (and this training will be completed following their induction) or on long-term sick.

This recommendation has now been implemented.

 Recommendation 2.4 

Owner: SPS 

The recommendation has been implemented.

Recommendation 2.5 

Owner: SPS, NHS and Scottish Government 

The recommendation has been implemented.

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: The data sharing agreement between SPS and COPFS is at an advanced stage and with SPS legal service for clearance.

Next key actions: COPFS and SPS continue to develop a process for the earlier sharing of information from the DIPLAR report by SPS. COPFS is developing new policy guidance to support the earlier provision of factual information in all Custody Death Unit investigations, including those where there is still the potential for criminal investigation. The new policy will provide clear guidance to legal staff on the consideration of potential prejudice to any later proceedings, to allow a proportionate and consistent approach to be taken to risk, balanced against the wishes of nearest relatives.

Recommendation 3.3 

Owner: SPS and NHS 

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: The new SPS 'Post Traumatic Incident Support and Resilience policy' is being developed, due to be finalised in March 2024. The policy will set out the arrangements for the provision of post incident support following traumatic and critical incidents in the workplace. Identified a policy model by Fire Brigade Scotland, that consider best meets needs. The intention is to follow a similar approach, but SPS process will make use of resources available via their Occupational Health Provider (OH). It will include a trauma helpline, watchful waiting period and psychological Impact self-assessment tool.

Next key actions: SPS is looking at introducing peer support training model based on psychological first aid principles delivered through a train the facilitator model provided by Lifelines Scotland. Lifelines Scotland to develop a bespoke module/ website resource for the staff group focused on resilience and self-care, aim to launch May 2024. SPS seeking funding for a psychological surveillance questionnaire that would be issued to dedicated peer responders/ Governor in Charge, who may be more likely to be exposed to multiple incidents. If the employee requires trauma based, these will be recommended to SPS via OH and if approved will be progressed.

Recommendation 4.2 

Owner: NHS (to lead) and SPS 

Progress made: SPS have commenced the roll out of the Scottish Trauma Informed Leadership Training (STILT) to senior management teams in Establishments and across HQ directorates. SPS have commissioned an Evaluation of Trauma Informed practice across the SPS. Further research is currently being undertaken by a PhD student, who is interviewing SPS senior leaders to gain their perspective on what Trauma informed practice may look like in the SPS. No dates agreed at present for completion. Three new training modules to support staff in trauma practice from the NHS Scotland psychological First Aid suite have been added to the e-learning platform and are available to all staff

Next Key Actions: First of the STILT sessions will take place in HMP Edinburgh in March 24. It is anticipated that the training will be rolled out throughout the year. An interim report for the evaluation of trauma informed practice is scheduled to be submitted by the end of March. A final phase 1 report scheduled for May 2024.

2.6 Key theme: SPS and NHS documentation concerning deaths

Recommendation 5.1

Owner: SPS (to lead) and NHS

The recommendation has been implemented.

Recommendation 5.2 

Owner: SPS (to lead) and NHS

The recommendation has been implemented. 

Recommendation 5.3 

Owner: SPS 

Progress made: SPS have reflected on advice offered in respect of the perceived independence and role of the DIPLAR Chair and wish to take further time to consider these issues including both the skill set required and breadth of involvement across the full range of DIPLAR circumstances. Any final decision will cover how best to source/locate a future Chair and will require further discussion with their Advisory Board.

Recommendation 5.4 

Owner: SPS 

The recommendation has been implemented.