Understanding and Preventing Deaths Working Group minutes: September 2022

Attendees and apologies

• Gill Imery, External Chair, Oversight of Recommendations of Independent Review into Response to Deaths in Prison Custody
• Linda Allan, Co-Chair, Honorary Professor, University of Glasgow and family representative
• Wendy Sinclair-Gieben, HM Chief Inspector of Prisons
• Jane Kelly, Service Manager, Care Inspectorate
• Katie Godfrey, Mental Health in Prisons Lead, Scottish Government
• Laura Hoskins, Head of Policy and Improvement, Community Justice Scotland
• Dr Craig Sayers, Clinical Lead, National Prison Care Network, NHS
• Catherine Haley, Senior Inspector, Healthcare Improvement Scotland
• Neil Gentleman, Inspector, Care Inspectorate
• Shirley Windsor, Lead for Public Mental Health, Public Health Scotland
• Fiona Wilson, Mental Health and Suicide Prevention, Scottish Government
• Henry Acres, Drugs Policy Team, Scottish Government
• Eilidh Cunningham, Assistant Programme Manager, National Prison Care Network, NHS
• Laura Begg, Community Justice, Scottish Government

Apologies:

• Nicola McAndrew, Prisoner Healthcare Team, Scottish Government

Items and actions

Welcome and introductions

Gillian Imery thanked everyone for attending and introduced Linda Allan to the group as co-Chair. Gillian Imery thanked Linda Allan for agreeing to this role and explained that Linda Allan was co-Chairing in her capacity as a researcher and honorary professor as well as having direct experience of the death of a loved one in prison. The group were reminded that the purpose of the group was not to discuss individual circumstances.

Minutes of last meeting and terms of reference

Minutes of the previous meeting had been circulated and no comments received.

Draft terms of reference for the group had also been circulated and the group were asked to provide any comments they had on these.

Background and vision for progression of recommendations 1.1 and 3.4

Gillian Imery invited Wendy Sinclair-Gieben, as one of the co-authors of the Independent Review to provide more detail on the thinking behind these recommendations and how it was envisaged they would be progressed.

 Wendy Sinclair-Gieben explained that these recommendations were as a result of three factors, which relate to the States human rights obligations, including Articles 2, 3 and 8 of the European Convention on Human Rights.

- Article 2, places duty on the state to protect life effectively and people in prison are inherently vulnerable. There is an assumption people are safe in prison. The number of deaths in prisons is consistently rising and has doubled since 2010.

- Felt there were inadequacies in the way the State currently investigated deaths and failing to meet Article 2 obligations. These included limited opportunity for family involvement in FAIs, lack of findings following a FAI and the length of time between the death and the FAI leading to learning opportunities being lost. Likewise internal investigations conducted by SPS and NHS have limited involvement with families and their views on what could have been done differently. Families are deeply distressed and don’t have their questions adequately answered.

- Lack of public oversight of what are the causes of deaths and what is the prevention. The SPS and NHS undertake an in depth review following a death and monitor and produce reports but none of that is available publically.

There was a discussion amongst the group about whether the SPS should be represented on the group. It was acknowledged that there was a conflict with the agency delivering a service being part of a group who should be independently scrutinising that service. Conversely, their presence would bring operational knowledge and they will need to work in partnership with the NHS to deliver any framework. It was agreed that the SPS should be invited to the group if there were aspects of the framework they should be consulted on.

Neil Gentleman asked Wendy Sinclair-Gieben for insight into her vision as to how the new framework should look.

Wendy Sinclair-Gieben explained that fundamentally what was been done at the moment wasn’t working and there needed to be greater consideration of the deaths that were occurring and why. For example, although some deaths were deemed to be ‘natural cause’ more should be done to look at the history behind that and whether issues like lack of transport provision to appointments may have compromised outcomes.

Wendy Sinclair-Gieben suggested that one ‘quick fix’ would be a system for families to raise concerns with the SPS 24/7, 365 days. Currently it was difficult to get through to a prison and be taken seriously.

Jane Kelly commented that there were a number of good policies written aimed at preventing deaths but not being consistently applied across prison estate. Questioned whether there may be a benefit in conducting a policy review.

Cath Haley advised the group that HIS were looking at a standardised approach to Adverse Events reporting. Going to review the current framework and families would be at the heart of that. There can be inconsistency in the interpretation of what is a significant near miss or adverse event. Aim is that if reporting structures are the same nationally then it should help identify any trends.

Linda Allan commented that if health boards were complying with their duty of candour they should be reporting centrally to government certain incidents and these shouldn’t be looked at separately.

Craig Sayers commented there was no consistency in different health board with the reporting of adverse events and a more standardised approach was welcomed.

The group were advised that it is difficult getting healthcare staff to work in prisons. Often they face criticism from others around their career choice and there are lots of other opportunities within the NHS. In Forth Valley, they had experienced success in recent recruitment exercises but then quickly losing staff for number of reasons, such as lack of career pathway and lack of feeling supported and safe.

Governance and work of the National Prison Care Network

Craig Sayers provided the group with an overview of the work and governance of the National Prison Care Network. Advised that they were a strategic, advisory board. Don’t have the power to tell health boards what to do. Very small team and lots of asks of the network. These come from a number of sources such as strategic direction from sponsors in Scottish Government, Ministerial requests such as the deaths in prisons work, SPS requests and healthcare manager requests. The Network has to prioritise these requests.

In terms of governance, there are a number of facet groups which comprise of individuals with expertise. They report to the Prison Care Core Steering Group. Once an action has been agreed by that group it is escalated to the Scottish Health in Custody Oversight Board. That group is chaired by the Chief Executive of an NHS Board.

Craig Sayers advised that the National Prison Care Network were trying to get a higher profile and visibility of the deaths in prisons work by NHS Board Chief Executives and Regional Board leads.

Mapping exercise of current work/strategies of potential relevance to creation of framework for preventing deaths

Group were thanked for their contributions in advance of the meeting for providing details of any ongoing policies/strategies they were aware of that were potentially of relevance to preventing deaths in prisons. A table including all of these strands had been circulated to the group.

Linda Allan reflected that there was lots of policy and good intentions but still deaths in prisons were increasing and there was a need to do something about it. Also a need to know how good policy is then delivered by prison officers on the ground doing their jobs. There should be delivery dates and detail of what actually trying to achieve.

Group felt the main documents were the healthcare needs assessments. Group requested more information about the plan for them being actioned. There was an appreciation that SPS and NHS staff are under a lot of pressure. Also commented that this was not a silo piece of work and required justice and health to work together to deliver.

Gillian Imery advised the group that there were still gaps in the data available to the group about causes of deaths. Have previously reached out to justice analytical service and also exploring with NRS the extent to which they can compare deaths in prisons to those in the community.

Craig Sayers commented that research had been done previously that demonstrates prisoners typically from a poor healthcare background and experience a physiological age on average 10 years older than their chronological age.

Another particular issue he was aware of in assessing prisoner health is the inadequacy of electronic records. The consequence is the inability to pull data on how many people suffer from a particular health condition. There is a need for better electronic recording of health care conditions.

Henry Acres advised the group that the drugs death taskforce had encountered the same issues with data around drug use in prisons. The group were updated that the drugs policy team are trying to drive forward some of the actions from the report and are due to give a session at Committee in October. Will be developing a cross-government action plan and look at concrete actions after exploring what other policy areas can deliver. Following that should be able to provide more detail around what was happening and when.

There was a discussion around some of the other known challenges facing the provision of healthcare to prisons. These included outdated IT systems and lack of electronic prescribing, lack of facilities for elderly prisoners, lack of targets to reduce the numbers of death and fiscal challenges. It was commented that there was a disconnect between a long term policy vision of a reduction in custodial detention and what was happening in practice. It was also commented that prison rules are inhibitory and not fit for purpose.

Laura Hoskins commented that prevention had to be considered in the context that we lock up more people than any other country in Europe and arguably lock up lots of people who shouldn’t be locked up. May be merit in looking at frameworks in other countries in respect of prevention of deaths in prisons.

There was a discussion about how much was invested in the scrutiny of healthcare in prisons and the scrutiny of the justice sector as a whole. It was commented that these oversight bodies had very small teams.

There was a discussion about whether there was any capacity to commission a researcher to conduct a review into the causes of deaths in prisons. It was commented that this would help place an obligation on the SPS to share data. Gillian Imery advised the group that she had no budget to commission this. Could potentially raise at her next meeting with the Cabinet Secretary.

Creation of workplan and next steps

Linda Allan commented that she felt a deliverable of the group should be more accessible data, similar to the Scottish Learning Disabilities Observatory. That the group should consider the existing oversight standards and whether there was room there for improvement.

Jane Kelly volunteered to take an action to provide the group with information about the journey of the model of the Child Death Hub which sits with the Care Inspectorate.

Craig Sayers informed the group that the Network are helping facilitate best practice sharing amongst healthcare professions. A prison GP forum has been established and trying to do the same with prison nurses.

Shirley Windsor advised the group that PHS are exploring the potential to pull together drug death review and suicide death review processes, including data recording across all setting including prison settings.

Any other business

None

Actions

• Linda Allan to draft a work plan to circulate to the group for comments
• Linda Allan to explore with potential academics possibility of being involved in a review of causes of deaths
• All to consider draft Terms of Reference and provide any comments to Laura Begg
• Jane Kelly and Neil Gentleman to provide information to the group about the Child Death Hub
• Prisoner Healthcare Team to be asked to provide information to the group about the prisoner healthcare needs assessments and plan for implementation