Why deaths of 123 prisoners in Scottish jails remain unexplained

The researchers have called for improvements in the nation's fatal accident inquiry system saying that since reform in mid-June 2017 there have been 201 deaths in prison and 123 of these were still awaiting an proceedings to start.

And on average FAIs completed in 2021 and 2022 took over two years to complete with no improvements since last year.

FAIs are held to investigate deaths in industrial accidents, in prisons and for deaths where it is felt necessary to hold a public inquiry.

Under the Fatal Accidents and Sudden Deaths (Scotland) Act all prisoner deaths must be the subject of a Fatal Accident Inquiry to establish the circumstances of the fatalities. It is the responsibility of the Crown Office and the Procurator Fiscal Service to ensure that this happens.

The researchers say that while Covid infections had an impact on the number of deaths,  with 15 dying from the virus, it was the increase in deaths from suicide and drugs that has been the most significant impact.

Some 29 of the deaths were suicide, 25 were related to drugs and 42 were attributed to ‘other’ causes such as medical conditions.

The analysis found a person who was imprisoned in 2022 in Scotland would be twice as likely to die in jail as someone in 2008.

Co-author of the report, Professor Sarah Armstrong, University of Glasgow, said continued Covid restrictions has led to prisoners becoming isolated and distressed.

The figures, published in the Still Nothing to See Here report come one year after a critical report by the same authors which examined around 200 fatal accident inquiries (FAI) into deaths in prison across a 15-year period.

They found that in 90% of cases sheriffs determined nothing could be done to prevent or foresee the prisoner’s death.

The report said that after a year the problems identified with FAI’s remain unchanged.

It said that as of October 2022 sheriffs identified even fewer precautions, system defects or recommendations, and family involvement remained low.

The report states: “The analysis of this public data raises some significant questions about the quality and contribution of the only public system of death investigation in Scotland for those who die in the state’s custody, and one wonders how Scotland’s high level of death in prison can be addressed without regular oversight of deaths or the system of investigating them.”

The report authors raise questions around the efficacy of the Scottish Prison Service’s preventative suicide strategy called ‘Talk to Me’.

From reading hundreds of FAI determinations, the research team found that those prison and health care staff who testified during these inquiries were reluctant to implement a prison Talk to Me strategy because “of its worsening impact on prisoner wellbeing” which was never questioned by sheriffs.

Honorary Professor Linda Allan commented: “As with last year’s review, time and time again the Crown Office are not presenting systemic failures. From the narrow focus of individual cases where prisoners say they have no thoughts of self-harm and appear otherwise well to non-mental health professionals was sufficient for sheriffs to conclude a person was at no risk of suicide, often despite many other markers of risk including previous attempts of suicide and recent life changing events.”

Official figures show that fatal inquiries in Scotland outside of prison deaths are taking almost three years on average to complete.

There are now proposals for a Victims’ Law to be introduced which would put in place a statutory time limit for inquiries to be completed.

Official figures show that over the last year, the average time taken to close an inquiry was 1,067 days.

It is an increase of 128 on the average time taken to complete an inquiry in the previous year.

Last month family of  one prisoner who died in custody called for FAIs to be abolished, telling the First Minister in a letter that the system “does not serve the families, but only gives false hope”.

Allan Marshall, 30, was being held on remand at HMP Edinburgh in March 2015 when he suffered a cardiac arrest during a lengthy struggle with staff.

A fatal accident inquiry (FAI) found that Mr Marshall’s death was “entirely preventable”.

Honorary Professor Armstrong said changes were need in prisons to prevent deaths.

“There are very few mandatory Covid restrictions affecting people outside prison, but these continue inside Scottish prisons, including reduced face-to-face visiting, less opportunities to spend time outside of cells, and fewer members of staffing. After many years of research, it is widely accepted that this kind of prolonged isolation causes significant mental distress," she said.

“While the numbers of people dying in prisons remains deeply disturbing, the fact it has accelerated under these conditions and led to more deaths from causes associated with distress, despair and isolation such as suicide and drug-related deaths, is not surprising.

“We would therefore urge the Scottish Prison Service to take urgent action to lift those restrictions and make improving mental health a priority for those in prison.”

A spokesman for the Crown Office and Procurator Fiscal Service said: “COPFS takes very seriously its contribution to Scotland’s response to deaths in custody.

“We have created a specialist investigations team to focus on these cases and are part of a multi-agency action group which is driving improvement.

“We feel this research paper does not fully capture the practical application of FAI legislation and would be pleased to meet with its authors.”

A Scottish Government spokesman said: “The safe treatment and mental health of all those in custody is a key priority for Scotland’s prisons, which care for people with higher levels of risk and vulnerability than the general population as a whole.

“The Crown Office has significantly reformed its processes to reduce the time taken to investigate deaths and to bring FAIs to court more quickly. It is for the presiding Sheriff who has heard all the evidence, to determine what recommendations, if any, should be made.”

A Scottish Prison Service spokesman said: “We recognise the profound emotional distress experienced by families when a loved one dies in custody.

“Our vision is for people within our care to have the best possible health and wellbeing and, where mental health problems do occur, that they get the respect, support, treatment, and care they require.

“We work closely with NHS partners to develop individualised plans, and provide contact with Samaritans, where trained Listeners provide additional support. Talk To Me, developed in partnership with experts in suicide prevention, provides person-centred care for those most at risk.

“We are working with partner agencies to deliver overdose awareness activities, recovery cafes, and wider support services.

“During the Covid pandemic we implemented a “Prison 2 Rehab” pathway, giving people access to rehabilitation programmes directly from the point of liberation.

“And the introduction of photocopying of mail has led to a significant fall in both incidents of drug-taking, and emergency ambulance calls related to substance misuse.

“We also have increasing numbers of older people in our care, with the same health and care challenges as seen in the wider community, and high levels of health inequalities faced by our population as a whole.”

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