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SHERIFFDOM OF GLASGOW AND STRATHKELVIN AT GLASGOW
Court ref: GLW-B366-23
RESPONSE
to the
DETERMINATION OF SHERIFF HANLON
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC. (SCOTLAND) ACT 2016
IN THE
INQUIRY INTO THE DEATHS OF DECLAN GALLACHER AND DAVID BERRY
To: the Scottish Courts and Tribunals Service
Recommendation 1
That Police Scotland update the National Custody System (NCS) to include a separate mandatory field confirming whether a strip search of a prisoner is to take place, as well as recording that the decision has been communicated to the prisoner and the officer to conduct the search.
Response 1
Following the Inquiry, Police Scotland has communicated the importance of the accurate recording of the information on the requirement for a strip search on the NCS in its current format. A policy position is also being processed that will require the decision on strip search to be communicated to the prisoner at the charge bar and on CCTV to ensure clarity of instruction.
Internal audit and assurance is being carried out to ensure compliance via the Custody Audit & Assurance Framework. This Framework is due to be completed by 31st October 2025.
A request has been made to Information and Computer Technology (ICT) to update the system by adding the recommended function.
Recommendation 2
That Police Scotland update the National Custody System to introduce a mandatory field in the processing of prisoners, confirming that system checks of all relevant databases has been completed in relation to each prisoner.
Response 2
Database checks are currently carried out effectively using a paper based checklist. In order to allow the electronic recording of these checks a request has been made to ICT to add this function to the NCS.
Recommendation 3
That Police Scotland update the National Custody System to ensure that, whatever level of constant observation is decided upon for a prisoner, the system allows custody officers to separately choose the appropriate regime for prisoner visits without having to first change the level of constant observation to a lower level.
Response 3
The Inquiry heard that when a prisoner is placed on Level 3 constant observations the NCS automatically defaults to a visit regime of 60 minutes meaning the system will alert at the time a visit is due. A more frequent visit regime can be imposed whilst a prisoner is on Level 3 constant observations however the system will not alert at the earlier interval chosen. Alternatively, if a system alert is sought, whilst maintaining the prisoner on Level 3 constant observations, level 2 could be selected on the NCS to enable alerts at earlier intervals.
Police Scotland are currently undertaking a project, Custody 2030, to review the process for assessing risk and vulnerability within custody and to consider the effective police management of same. This review must be carried out prior to any update to the ICT as recommended. The allocating of visit regimes is being considered as part of this project and as such any update must be considered in line with the overarching approach and policy of assessment of risk and effective management of vulnerabilities in custody.
Once this assessment has been completed, appropriate updates to the NCS will be undertaken. This project is underway and is complex. No fixed date can be given for completion at this stage however a target date of Quarter 1 or 2 of 2026/2027 would be proposed.
Recommendation 4
That Police Scotland give urgent consideration to introducing formal written guidance to officers as regards the maximum ratio of observing officers to prisoners for constant observations.
Response 4
The Inquiry heard that some research had been carried out by Police Scotland into safe observation ratios however no definitive conclusion was able to be reached. A further review is currently being undertaken to ensure suitable guidance is developed and communicated to custody officers and staff on appropriate ratios for constant observation.
This review must be robust, and requires an evidence-based approach to ensure the correct ratio is in place. The target date for completion of this research and implementation is 31st January 2026.
Recommendation 5
That Police Scotland give urgent consideration to introducing a formal policy, set out in its Standard Operating Procedures, as regards the period following which a break should be provided for officers conducting constant observations, and to introducing a system whereby such breaks are the subject of a system of recording.
Response 5
The Inquiry heard that there is currently guidance in place for officers in relation to allocation of breaks for those carrying our constant observations.
To ensure further suitable guidance is developed and any formalised procedure introduced and included in the Standard Operating Procedure, a full review is being undertaken. As with observation ratios, this review must be robust and involves an evidence-based approach to ensure the correct procedure is implemented. The target date for completion of this research and implementation is 31st January 2026.
Recommendation 6
That Police Scotland introduce a module of training on constant observations, formally outlining what the duty entails, the risks involved, what signs to look for and what action to take in potential scenarios, and that an accessible record be kept to ensure that those placed on constant observation duties have completed the appropriate training.
Response 6
The introduction of training on constant observations is currently under review together with the issues raised in Recommendations 4 and 5.
Consideration is being given into the proposed content of such training together with method of delivery. Given that the role of conducting constant observations is not limited to custody staff, the roll out of this training will include the thousands of officers employed by Police Scotland within Local Policing Divisions. The target date for the finalising of the proposed training is 31st January 2026.
Recommendation 7
That Police Scotland, in collaboration with the NHS healthcare hub staff, review the guidance to police officers as set out in the Standard Operating Procedures in relation to when a referral of a prisoner to a Health Care Professional should be made, that it sets out with greater clarity the criteria used in deciding whether a referral should be made, and addresses the issue of whether or not there exists any minimum wait time for a Health Care Professional to attend.
Response 7
As heard by the Inquiry, healthcare provision to those in custody is the responsibility of the individual NHS Health Boards. Police Scotland is actively engaged with the NHS to ensure a consistency of approach can be achieved and to develop a baseline set of standards.
The National Police Care Network is a key strategic network which supports and facilitates the delivery of healthcare services in police custody, as well as forensic medical service delivery. The network acts as a conduit between Police Scotland, NHS boards and Health and Social Care Partnerships. It ensures that these services are co-ordinated, optimised and supported at a national level. A primary piece of work currently underway relates to the delivery of a national Target Operating Model which seeks to bring a set standard to health care provision to those in police custody across all 14 Health Board areas. Given the complexities and challenges associated, no fixed date for implementation can be provided at this time.
However, whilst this collaboration with the NHS Health Boards is progressing, Police Scotland will carry out a review of their internal policies associated with this to take account of this recommendation and consider any changes required. Any internal policy changes have a target date for implementation of 30th November 2026.