Death in Prison Custody: action plan - updated November 2023

2. Progress on recommendations 

2.1 Theme: Key Recommendation

Recommendation 1 

Owner: Scottish Government 

Progress made: The draft process was 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 initial desktop pilot exercise took place over two days in October. Number of issues raised will feed into the evaluation process.

Next key actions: The MOU and ISAs to be finalised. Dates in January have been identified for second desktop pilot exercise. Evaluation exercise of first pilot to commence and all organisations will feed into that process.

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) published an initial report on deaths in prison between 2012-2022. JAS are leading on a further report with NRS which will include comparisons with trends in general population. The NHS are progressing the revised guidance on clinical management of people suspected of intoxication (MORS) and the GP forum has provided feedback.

Next key actions: JAS and NRS report should be ready for publication in spring 2024. The revised MORS guidance needs shared with NHS Boards and SPS for feedback prior to sign off and implementation.

Recommendation 1.2 

Owner: NHS (to lead) and SPS 

Progress made: NHS Toolkit has been circulated with Boards and SPS, as well as presented to the Family Reference Group. NHS Board Chief Executives (BCE)were made aware of the recommendations and actions required and have asked to informed on progress. FAI training for staff was held in September 2023, positive feedback has been received. FAI Support resources were circulated to Boards.

Next key actions: Following final amendments the Toolkit will be circulated for implementation.

Recommendation 1.3 

Owner: SPS 

Progress made: SPS are installing all dedicated phonelines across the establishments, there were some delays around data points and cabling. Accompanying standard operating procedures and processes to audit have been developed and the 'Raising a Concern Booklet' will be updated with the phone numbers before going live.

Next key actions: Final installation is anticipated by November 2023. There will be a system test before going live by December 2023.

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: The confirmation of death training has been made accessible to staff. Confirmation of death pocket cards have been distributed to prison health centres.

Next key actions: NHS will circulate data request to identify number of Prison Nurses who have accessed the confirmation of death training throughout October and again in January (with the aim to have 100% of nurses complete the training by then). Refresh Prison Induction resource to include this training.

 Recommendation 2.4 

Owner: SPS 

Progress made: On 31 August 2023, a Governors and Managers’ Action Note was issued to all prisons to advise that the revised DIPLAR Report template and guidance document are to be implemented with immediate effect. The SPS Chaplaincy team will remain a key support both immediately and in the longer term following a death.

The recommendation has been implemented

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, this includes a specific section that requires confirmation that an assessment of whether the rights of the child have been adhered to, if the death involves an individual under the age of 18 years. This has been added into the new DIPLAR process, template and guidance. Where the death of a child or young person occurs, their Lead Professional or Named Person must also attend 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. The NHS Toolkit includes guidance on duty of confidentiality in respect of deceased patients and how to consider requests for information by relatives of deceased patients.

Next key actions: SPS are awaiting feedback on the Information Sharing / Data Sharing Agreement from COPFS.

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: 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.

SPS attended the Family Reference Group in July 23 to update them on the work being progressed to support staff. SPS are attending the EuroPris meeting 10/10/23 to discuss approaches with European counterparts. From review of various models, SPS are favouring the Scottish Fire and Rescue Service approach and linking this with peer support training like psychological first aid. This can be delivered via Lifelines, and plan to approach them for an idea of costs. SPS have drafted a document as support for staff attending FAIs. The NHS have included a "NHS Staff Wellbeing and Support" chapter within Toolkit. NHS Boards have been asked to ensure that monthly supervision/1-to-1 meetings take place and that following a death in custody staff are asked about their wellbeing.

Next key actions: SPS are attending a Penrith facility in November 2023 to review the facility and support that can be provided there. Meetings are to be arranged with Cruse to discuss bereavement and suicide support. SPS will further progress the FAI documents and finalise them to make them available to staff.

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.