Some 39 of the 43 recommendations made by the Fatal Accident Inquiry (FAI) into three deaths at HMP & YOI Polmont have been implemented, but there is still more to be done.
After 10 months of operation, Scotland’s ministerial accountability board (MAB) has delivered its final report on the implementation of recommendations following prison custody deaths. It notes considerable, measurable progress but acknowledges there is more still to do.
Photo by Eli Solitas / Unsplash
Among the positives, the Scottish Prison Service (SPS) is introducing a new suicide prevention policy, while all courts in Scotland have been directed to routinely provide prisons with any pre-sentence reports available to the court. ‘Signs of Life’ technology has been installed and piloted in two prisons, alongside the introduction of an enhanced admission process for young people in their first 72 hours.
Since April 7 last year, where there is a fatal accident inquiry into a death in custody, families can access free and non-means-tested legal aid. There are plans to expand this access in the near future. The Scottish government is also now considering recommendations made by Sheriff Principal Abercrombie’s independent review on how to reduce FAI timelines, and the lessons learned by the MAB will inform the development of a National Oversight Mechanism to provide independent oversight and scrutiny of deaths in prison custody.
This is all in response to the joint FAI determination, issued by Sheriff Simon Collins KC in January 2025, which concluded that significant environmental and systemic defects led to the preventable deaths by suicide at HMP & YOI Polmont of Katie Allan in June 2018, William Lindsay (also known as William Brown) in October the same year and Jack McKenzie in September 2021. The FAI identified numerous failures by the Scottish Prison Service (SPS) and the NHS, and made an unprecedented 43 recommendations. These were accepted in full by the Scottish government in March 2025.
The independent MAB was established in June 2025 to oversee implementation of these recommendations. Chaired by Justice Secretary Angela Constance, it comprised six independent members drawn from legal, academic, operational, public health and third-sector backgrounds.
Family members of Katie Allan and William Lindsay attended two meetings of the MAB, directly informing the final conclusions. Representatives from MAB also attended a Family Listening Day in October 2025 to hear bereaved families share their experiences. The day was facilitated by the charity Inquest and commissioned by the Scottish Human Rights Commission.
Angela Constance MSP, Cabinet Secretary for Justice and Home Affairs, says: ‘The preventable deaths of Katie and William were profound tragedies – as is the loss of life of any person in the care of the state. The MAB’s final report delivers a strong message across the system about the accountability and action needed to ensure such failures are never repeated. I extend my sincere thanks to the members of the Board for their time, expertise and candour. Most importantly, I acknowledge the families who have lost loved ones in custody, for their tireless efforts to demand change and their engagement with board members during this process.
‘The final progress report shows that there is a strong and credible foundation to implement the further necessary reforms to improve safety for young people in our care, but we know there is more work to do. I was particularly struck by the recurring theme raised by board members around the gap between good policy and good practice. That gap must be closed, and I am hopeful that the actions we have taken this past year have made significant steps towards that goal.’
Sam Gluckstein, Senior Expert Adviser to the Inspectorate of Prisons Ireland and a member of the MAB, adds: ‘The MAB’s work over the past year has been an important and overdue step in strengthening accountability and learning lessons from past tragedies. Progress has been made, but the real measure of success will be whether reforms move beyond policy commitments and lead to safer practice for people in custody. Preventing deaths in prison must remain an urgent priority.
‘One preventable death is too many. The Board has monitored the implementation of recommendations arising from the deaths of three young people — Katie, William and Jack — but there were deaths before them, and there have been deaths since. Our work has aimed to maintain momentum behind reforms and ensure accountability for their delivery. That progress must now continue with pace and focus.’
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