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In November 2019, the Cabinet Secretary for Justice, Humza Yousef announced that he had asked HM Chief Inspector of Prisons for Scotland (HMCIPS), Wendy Sinclair-Gieben, in accordance with section 7(2)(d) of the Prisons (Scotland) Act 1989, to undertake an independent review into the handling of deaths in prison custody.

The Review was instructed to enable the identification of and to make recommendations for areas for improvement to ensure appropriate and transparent arrangements are in place in the immediate aftermath of deaths in custody within Scottish prisons, including deaths of prisoners whilst in NHS care.

It was later announced that Professor Nancy Loucks OBE, Chief Executive of Families Outside and Judith Robertson, Chair of the Scottish Human Rights Commission will join Wendy Sinclair Gieben as co-Chairs of the review. 

Families Outside will provide external expertise to inform the views of support for families and the Commission will conduct a comprehensive analysis of the relevant human rights legal standards, at both the European and international levels. Both co-Chairs will also work across the other work streams that are part of the Review.

Read the Terms of Reference for the Independent Review into the Handling of Deaths in Prison Custody. 

Activities to date

Preliminary work for the Review began in February 2020 and despite some delays due to COVID-19, the Review has moved forward. The Review had nine work strands and many of those are now in the final stages while others are still in their infancy:

Literature Review: A draft literature review has been completed and is informing next steps.

Human Rights Analysis Framework: A draft Framework is being reviewed and provides the underpinning principles and the benchmarking for the remainder of the research.

Examination of the arrangements, policies, training and operational procedures in place within the SPS and NHS relevant to deaths in custody: All requested SPS relevant documentation is being gathered and distributed. The Review Team researchers will be analysing it against the human rights standards in the Human Rights Analysis Framework.

Examination of the arrangements in response to a death in custody, including current processes within the SPS and NHS for the immediate Critical Incident Response and Support (CIRS) process and the subsequent joint Deaths in Prisons Learning, Audit and Review (DIPLAR) process, as well as the previous Self-Inflicted Death in Custody: This was deferred until the Human Rights Analysis Framework had been drafted to allow analysis against human rights standards.

Examination of the consistency and differences between previous FAI determinations and recommendations and learning arising from the DIPLAR process: This piece of work required the Human Rights Analysis Framework, information from the SPS, and the recruitment of additional research capacity to complete and will complete later in 2020.

Family engagement: This work has now begun. Some of the families who have agreed to take part in the review have also agreed to become part of a review advisory panel. The first meeting was well attended, highly informative and the Review team would like to thank everyone for their enthusiastic participation. All three organisations are using social media routes to encourage families of prisoners to engage with the review. In addition, the Review Team have advertised on social media and their respective websites inviting family participation.

Staff engagement: Letters and accompanying information and consent forms have been drafted and will be issued shortly.

Seeking the views of expert witnesses: Phil Wheatley, retired Director General from the National Offender Management Service (now HMPPS) in England and Wales has completed his expert review.

Key justice partners have agreed to contribute to the review and the Inspector of Prosecutions element has been submitted. .

The Review team still welcomes expressions of interest from families who may have been affected. The contact details are, or 07958 451334.

Family engagement

The Review co-Chairs believe that the experiences and views of families who have been affected by deaths in custody should be first and foremost in informing the work of the Review and its recommendations. Work to engage with families was suspended as a result of COVID-19 but has now begun.

This work will involve reaching out to affected families in a variety of ways to gain their perspective on how deaths in custody are handled, whether more could be done to support families affected by a death in custody, and the families’ views on preventing a death in custody.  

On behalf of Families Outside, the Crown Office is writing to families who have been involved in a Fatal Accident Inquiry since 2018, following a death in prison custody.  Read the letter here.  

The co-Chairs would also welcome the chance to hear from other families affected. Anyone affected can contact Professor Loucks directly at or on 07958 451334 to arrange a time for this. Input can be provided remotely via email or telephone / video call, or in person - individually as a family or in a small group with others – whatever makes you feel most comfortable. If you would be interested in participating in an advisory group for the Review, please  also let her know that as well.

The co-Chairs are also considering alternative ways of engaging with affected families over the coming months, taking into account ongoing restrictions arising from COVID-19.