SHERIFFDOM OF GLASGOW AND STRATHKELVIN AT GLASGOW

Court ref: GLW-B1670-24

RESPONSE

to the

DETERMINATION OF SHERIFF JONATHAN GUY

UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC. (SCOTLAND) ACT 2016

IN THE

INQUIRY INTO THE DEATH OF MICHAEL CHARLTON

        

To the Scottish Courts and Tribunals Service

 

1.     The Scottish Prison Service (SPS), being a body to whom a recommendation under section 26(1)(b) was addressed, do respond as follows.

 

2.    Recommendation 1 – As soon as reasonably practicable, the SPS should put in place a written system of work at HMP Barlinnie in relation to MORS that: 

·         Requires a specific officer to observe prisoners that have been placed on MORS and complete the observation documentation.

·         Requires managers to actively monitor compliance with MORS to ensure that the required observations are carried out during every shift.

·         Specifies the procedure that is to be followed in relation to the aspects of MORS that GGHB have refused to undertake.

·         Specifies that MORS does not provide authority for removing prisoners from association, and if this is deemed necessary, the appropriate procedure (such as that prescribed under Rules 41 or 95 of The Prison and Young Offenders Institutions (Scotland) Rules 2011) should be followed.

·         Requires healthcare staff to specify the type of observation that is to be undertaken for prisoners that have been placed on MORS when completing a prisoner’s care plan.  This should include the type of observation that requires to be undertaken for prisoners that are sleeping and when it is appropriate to wake them for the purpose of carrying out observations.

·         Specifies the procedure that is to be followed to ensure that officers coming on duty are made aware of the prisoners that have placed on MORS, as well as the frequency and type of observation that requires to be undertaken in respect of them.

3.     Response 1 - The SPS accepts points 2 - 6 of this recommendation and intends to put in place a written system of work in HMP Barlinnie by the end of August 2026 that will address these elements of the recommendation. In relation to point 1 of this recommendation, the SPS has determined that assigning a single designated officer to observe all prisoners managed under the Management of Offenders at Risk due to any Substance (MORS) policy would create significant operational risks. The role of a prison officer is inherently dynamic, requiring staff to respond to unpredictable situations across the establishment. As a result of this, it is neither practical nor safe to rely on one specific officer to maintain continuous observation. A flexible, team‑based approach is necessary to ensure consistent monitoring of prisoners while maintaining overall safety and security within the prison environment.

4.      Recommendation 2 - As soon as reasonably practicable, the SPS should ensure that it provides officers at HMP Barlinnie with suitable and sufficient training on this prison’s system for implementing MORS.

5.    Response 2 – The MORS policy review is underway, and a Short Life Working Group (SLWG) has been established to undertake this review. As part of the SPS MORS review, a formal training requirement will be developed for all operational staff to ensure suitable and sufficient training is provided on the revised MORS policy implementation. This training requirement will be applicable to all SPS prisons. At this time, the SPS are unable to provide a timescale in relation to the completion of the MORS review or the training implementation. Until training on the revised policy is delivered, HMP Barlinnie will implement targeted ‘toolbox talk’ awareness sessions for all operational staff. These sessions will focus on the existing MORS policy and the associated paperwork, reinforcing staff duties and responsibilities under the current policy framework.

6.     Recommendation 3 – As part of the audits that FLMs undertake at HMP Barlinnie in relation to MORS, they should investigate whether the failure by officers to complete the observation documentation is because they have not undertaken the required observations and ensure that any failure to comply with these aspects of the system is appropriately addressed.

7.     Response 3 – At HMP Barlinnie, audits undertaken by First Line Managers (FLMs) are completed at the conclusion of a MORS episode. Where issues are identified during these audits in relation to observation documentation, these will, in the first instance, be raised directly with the staff member by the FLM to highlight the concerns and associated risks. Where it is determined that observations have not been undertaken in accordance with the MORS care plan, in addition to the application of performance management procedures, SPS Code of Conduct procedures are likely to be considered.

8.    Recommendation 4 - As soon as reasonably practicable, the SPS should amend MORS so that it: Requires a specific officer to observe prisoners that have been placed on MORS and complete the observation documentation. 

·         Ensures that compliance with this policy is actively monitored by managerial staff during every shift.

·         Interacts with the TTM system in a manner that prevents officers from attributing the warning signs of suicide that Mr Charlton was exhibiting to intoxication.

·         Specifies that when a prisoner is placed on MORS their person and cell are searched to remove their access to illegal substances.

·         Specifies the type of observation that requires to be undertaken for prisoners that are sleeping, including when it is appropriate to wake them for the purpose of carrying out observations.

·         Does not include a requirement for another organisation (such as GGHB) to undertake tasks that they have not consented to undertaking.

9.     Response 4 – Points 2 - 6 of this recommendation will be considered as part of ongoing review of the MORS policy. Element (2): As part of the MORS review, SPS will review and revise the roles and responsibilities of all staff involved in the MORS policy, including managerial staff. Element (3): The MORS review will consider how best to interact the MORS policy with the SPS Suicide Prevention Policy (currently Talk to Me (TTM)), to make staff aware that warning signs can be attributed to both substance misuse and suicidal ideation. SPS recognises that these warning signs can overlap and consideration will be given to how best we streamline these processes to ensure those in custody who are presenting as under the influence are cared for in the most appropriate manner. Amendments to SPS training materials for TTM have already been completed following a determination from another FAI. This training now provides additional information to staff in relation to long term chronic or habitual drug and/or alcohol use, highlighting the impact this can have on an individual's risk of suicide. This updated training is now being delivered to all required staff as per training requirements. Element (4): The MORS review will consider any existing Standard Operating Procedures (SOPs) in relation to Cell Searching and conducting Dynamic Risk Assessments when an individual is managed on MORS. Element (5): It is the responsibility of NHS healthcare professionals to make appropriate clinical decisions based on their clinical assessments of each individual managed on MORS. Based on this assessment, NHS healthcare professionals complete a care plan which directs operational staff to observe the individual at a frequency the NHS determines as reasonable, based on their clinical assessment. SPS staff are not clinically trained to make decisions on how often an individual managed on MORS requires to be observed and this responsibility sits with NHS. This element of the recommendation will be raised by SPS with NHS colleagues for their consideration as part of the MORS review. Element (6): NHS prison healthcare in Greater Glasgow and Clyde (GGC), along with delegates from other health boards, are members of the MORS review Short Life Working Group (SLWG) and are actively contributing to discussions around developing the new MORS policy to ensure they are aware of and agree to undertake any tasks assigned to them under the reviewed policy.

10. As detailed at Recommendation 1 above, in relation to element 1 of this recommendation, the SPS has determined that assigning a single designated officer to observe all prisoners managed under the Management of Offenders at Risk due to any Substance (MORS) policy would create significant operational risks. The role of a prison officer is inherently dynamic, requiring staff to respond to unpredictable situations across the establishment. 

11.    Recommendation 5 - As soon as reasonably practicable the SPS should ensure that all its staff that are responsible for implementing MORS are provided with suitable and sufficient training in respect of this policy and the system for implementing it within the prison in which they work.

 

12.  Response 5 – As detailed in SPS's response to Recommendation 2, the MORS policy review is underway and as part of the SPS MORS review, a formal training requirement will be developed for all operational staff to ensure suitable and sufficient training on the implementation of the revised MORS policy across the SPS estate. At this time, SPS are unable to provide a timescale in relation to the completion of the MORS review or the training implementation.

 

13.   Training on the MORS policy has been developed for all new Operations and newly promoted Residential staff in 2022 and is undertaken at the Scottish Prison Service College (SPSC). This training covers the roles and responsibilities of officers, including how to complete the necessary documentation associated with the MORS policy.  

14.    Recommendation 6 - As soon as reasonably practicable the SPS should revise its TTM system so that it prevents officers from incorrectly attributing the warning signs of suicide that Mr Charlton was exhibiting to intoxication.

 

15.   Response 6 – The SPS is currently undertaking an overhaul of the TTM process and as part of this process, consideration will be given to how the SPS Suicide Prevention Policy will interact with MORS to raise awareness to staff that warning signs can be attributed to both substance misuse and suicidal ideation. As detailed in SPS's response to Recommendation 4, SPS recognises that these warning signs can overlap and consideration will be given to how best we streamline these processes to ensure those in custody who are presenting as under the influence are cared for in the most appropriate manner. Amendments to SPS training materials for TTM have already been completed following a determination from another FAI. This training now provides additional information to staff in relation to long term chronic or habitual drug and/or alcohol use, highlighting the impact this can have on an individual's risk of suicide. This updated training is now being delivered to all required staff as per training requirements.

 

16.  Recommendation 7 - A soon as reasonably practicable the SPS should carry out a suitable and sufficient assessment of the ligature risks within standard cells at HMP Barlinnie and eliminate any risks that are identified so far as is reasonably practicable.

 

17.   Response 7 – The SPS are currently working on the implementation of a ligature audit tool following a recommendation from another FAI determination. A proof of concept audit has been carried out, and during this it was recognised that the current audit tool (The Manchester Tool) is not sufficient in identifying the risk rating of the ligature anchor points within SPS cells. An external review has since been completed and a framework for ligature management within the SPS has been commissioned and is currently being progressed. The next steps involve reviewing and agreeing the ligature assessment process, alongside developing template documentation aligned with the national strategy. This process is ongoing and will provide SPS with the necessary tool to undertake such assessment as required by this recommendation for all SPS prisons.

 

18.    A Ligature Reduction Solution Panel has been established within SPS, having one of its roles to evaluate any new furniture or fittings being placed in SPS cells, to ensure we do not introduce additional ligature points into cell accommodation. An interim process has been introduced during this transitional period which requires Senior SPS HQ based staff to review any maintenance replacements or where replacements within cell environments differ from the original specifications.

 

19.  The SPS Death in Prison Learning Audit and Review (DIPLAR) Guidance was updated in March 2025 to include a requirement that, in cases where death has occurred by ligature, specific details are recorded within the DIPLAR paperwork. This includes the ligature point, the item used, as well as the location, cell type and overall condition. This ensures that the DIPLAR process gives due consideration to the safety and condition of the physical cell environment, including any damage, fixtures and fittings, and the availability of items that could potentially be used as a ligature.

 

20.  Recommendation 8 – The SPS should consider the failings in the DIPLAR in respect of Mr Charlton’s death to ensure that the DIPLAR system provides a suitable and sufficient method of establishing the cause of death of prisoners, any failings in relation to these deaths and the actions that require to be taken to ensure that other prisoners do not die in similar circumstances. 

21.   Response 8 – DIPLAR is the SPS process for reviewing all deaths in custody and provides a system for recording any learning and identified actions. The DIPLAR is not an investigation and does not determine a cause of death of any prisoner, the cause of death is rightly established by the postmortem, and the cause of death is provided to SPS via the medical certificate of the death.

 

22.  The SPS DIPLAR Guidance has been updated since Mr Charlton's death, most recently in March 2025 following extensive consultation. Key updates were made to the guidance and template including the introduction of an Independent Chair being required for all DIPLARs. The Governor or Deputy Governor will be required to attend to ensure they are content that the information recorded is accurate and as they have overall responsibility for any local actions arising. The Independent Chair of the DIPLAR meeting agrees with those present if action points are to be local or national level.

 

23.      Any National Actions identified at DIPLARs are centrally recorded and managed through the DIPLAR Action Response Group (DARG). DARG was established in April 2025 with membership from Managers and Leaders from the SPS Headquarters Health Team and SPS Operations Directorate. The group meet fortnightly to review progress against existing national DIPLAR actions and agree on requirements for new actions raised, including associated timescales.

 

24.  In addition to DARG, a Death in Prison Custody Assurance Group has been convened to provide oversight and governance of DIPLAR protocols across the SPS estate. This group is chaired by an SPS Director, and its remit is to provide leadership and set direction for DARG in addressing national actions contained in the DARG national action plan and to consider best practice to inform policy in relation to the prevention of deaths in SPS custody.

 

25.   Recommendation 9 – The SPS should consider its failures in respect of MORS and revise its system for implementing its policies, checking and monitoring that they are complied with and addressing issues of non-compliance identified within its prisons. 

 

26.  Response 9 - The SPS is strengthening its approach to operational assurance to provide the Operations Director and Chief Executive with greater confidence that operational policies, procedures, and controls are functioning effectively. This work will contribute to the development of SPS’s emerging Assurance Framework.

27.     As part of the second line of assurance, the Operational Audit Team was relocated to the Office of the Chief Executive from 1 April 2026 to enhance its independence from operational delivery.

 

28.   Moving forward, the Operational Audit Team is being expanded, with a renewed emphasis on risk-based auditing. Audit activity will increasingly focus on areas of higher operational risk, and actions arising from audits will be tracked in collaboration with the Operations Directorate. This reflects a strengthened commitment to delivering a more robust and effective secondary assurance, supporting the consistent delivery of high-quality prison services.

 

29.    The recommendations and learning from this Determination will be shared across the SPS to support wider learning and compliance.