SHERIFFDOM OF TAYSIDE CENTRAL AND FIFE AT PERTH
Court ref: PER-B265-23
RESPONSE
to the
DETERMINATION OF SHERIFF JENNIFER S BAIN KC
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS
ETC. (SCOTLAND) ACT 2016
IN THE
INQUIRY INTO THE DEATH OF REESE FAIRGRIEVE

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 – SPS should revise their national and refresher training in relation to locking / unlocking and numbers checks procedures to ensure that it accords with the realities of conducting such checks. To be effective, this training should be developed with sufficient input from operational staff, specifically governors, frontline managers and residential officers, and should reflect what is required of officers and what they are likely to encounter in the various cell types within the prison estate. Such national training should only be implemented once it has been approved at a prison governors meeting chaired by the Operations Director of SPS.

3. Response 1 - Following recommendations from another FAI determination, work has been undertaken to revise the national initial and refresher training packages in relation to locking/unlocking and numbers checks and a substantial redevelopment of a national e-learning package is in progress. The revised training places explicit emphasis on the practical requirements placed upon staff, including the need to work in pairs when undertaking these checks, the requirement to obtain a clear visual confirmation of the prisoner’s face, and the need to receive a verbal response sufficient to confirm the prisoner's welfare. It reflects the realities of operational practice, incorporating scenario-based learning through the use of videos, aligned to situations officers are likely to encounter across the prison estate. The training has been developed with input from operational staff, including operational managers, residential officers, and operational learning and development staff. This ensures the content reflects real-world practice and addresses concerns previously raised regarding a lack of operational input.

4. Formal engagement with Governors and SPS Operations Directorate has been planned as part of the final stage of its development and implementation, alongside work to introduce a local, work-based training. This will involve the observation of staff carrying out checks in line with local Standard Operating Procedures (SOPs) and formal confirmation of competence. Updates to the training package will be completed by the end of 2026 and this will then immediately be taken forward for engagement and approval for implementation.

5. Recommendation 2 - SPS training, policy and guidance materials in relation to locking / unlocking and residential numbers checks should be amended so that they are unambiguous and consistent with each other in relation to what is required of officers during these checks.  Greater emphasis should be placed on the welfare aspect of the cell checks and the heightened risk of prisoner death in the event of non-compliance.

6. Response 2 – SPS issued a Governors and Managers Action in March 2026 outlining updated procedures and a revised Prison Resource Library (PRL) standard for numbers checks. This reaffirmed the importance of numbers checks in monitoring the wellbeing of individuals in custody, emphasising the need to see each individual’s face and obtain a verbal response. Key changes require that any numbers check immediately before or after a Patrol Period is conducted by two officers working in pairs. Establishments were required to update local SOPs
to reflect these changes.

7. HMP Perth have updated their Residential Numbers Check SOP to reflect the changes made to procedures for numbers checks in line with SPS PRL Standards. This update ensures a consistency of approach and details the procedures that all staff must follow when carrying out prisoner management numbers checks. It specifically clarifies that in all residential halls, the numbers check will be carried out by two residential officers and each door will be physically unlocked to see the face of and gain a verbal response from all prisoners. These changes have been communicated to all operational staff through email within HMP Perth.

8. The training package in relation to locking/unlocking and numbers checks is being redeveloped alongside the review of relevant PRL standards, policies, and operational guidance to ensure alignment between training and national policy requirements. The revised training provides clear and unambiguous instruction on what is required of staff during locking/unlocking and numbers checks, reinforcing the mandatory need for visual and verbal confirmation. There is also an enhanced focus on the welfare function of these checks which is reinforced through scenario-based learning and case-studies. The training explicitly highlights that numbers checks are a critical safeguard for prisoner wellbeing and makes clear the potential consequences of non-compliance, including the risk of deaths in custody. Updates to the training package will be completed by the end of 2026 and this will then immediately be taken forward for engagement and approval for implementation.

9. Recommendation 3 – Prison Officers should be required to keep a contemporaneous documentary record of each cell check. The flatboard which is currently available and updated for each check, and which informs as to which prisoner is in which cell, should be revised to include a thumbnail image of each prisoner along with space to record which officers conducted the check, that the presence and identity of each prisoner within each cell has been confirmed and that a verbal response sufficient to ascertain the welfare of each prisoner has been received.

10. Response 3 – As advised during the FAI, SPS has determined that the process of keeping a documentary note of each numbers check across the prison estate would be burdensome upon a prison and there is minimal demonstrable value or evidence that such recording would enhance the accuracy, reliability or integrity of the numbers check process. Officers are required to undertake these checks on hundreds of prisoners, multiple times per day, and mandating a written record of which officers conducted the check, the presence and identity of each prisoner within each cell, alongside a record of the confirmed verbal response, has limited value and diverts staff from other operational duties. The SPS has considered this recommendation, however for the reasons outlined above, does not accept this recommendation as it is not considered to be a proportionate action.

11. As mentioned in response to Recommendation 1, training is being revised in relation to locking/unlocking and numbers checks and will be delivered across the prison estate to ensure that all operational front-line staff are appropriately trained on the numbers check process and are aware of the fundamental need for these checks to be carried out correctly.

12. Recommendation 4- Further provision should be made for compulsory ongoing refresher training at regular intervals to ensure that officers remain fully cognisant of the policies in place and the necessity of strictly adhering to the cell check procedures to ensure prisoner safety.

13. Response 4- Compulsory annual refresher training is currently in place for staff via the SPS Online E-learning platform and is delivered as part of the Control and Restraint training package. The revised training, as mentioned in response to Recommendation 1, will then form part of this cycle, ensuring that staff continue to receive regular and consistent input on procedural requirements and their role in ensuring prisoner safety.

14. In addition to national refresher training, further work is underway to enhance practice-based assurance through the introduction of a local competency sign-off process. This will involve the observation of staff carrying out checks in line with local SOPs and formal confirmation of competence, as mentioned in the response to Recommendation 1. Updates to the training package will be completed by the end of 2026 and this will then immediately be taken forward
for engagement and approval for implementation.

15. Recommendation 5- All such training should be centrally recorded and only such officers as have received the appropriate training and are aware of the SPS policies in relation to cell checks should be appointed to the role of residential officer.

16. Response 5- All new residential officers currently receive training at the SPS College in relation to locking/unlocking and numbers checks before commencing duty in an establishment. This covers the fundamental elements of the procedures and operational significance of numbers checks and the possible physical and environmental challenges or scenarios faced with opening cell doors. Compulsory annual refresher training is also in place via the SPS Online ELearning platform and completion of this training is centrally recorded and monitored by the SPS College.

17. Following a recommendation from another FAI determination, a review of SPS 'acting-up' induction practices was undertaken. Any officer across the estate who is ‘acting-up’ to a residential role must complete a mandatory induction process which must be recorded and signed off by their First Line Manager prior to commencing duty. This includes specific awareness or training in relation to numbers checks and unlocking procedures. A written record is kept in the officers’ training record and a record of competent 'act-up' officers is maintained and updated by each establishment. This process is supported by the HR Business Partners and Local Learning and Development Managers within each establishment.

18. Recommendation 6- Where CCTV is available it should be reviewed at specified intervals by governors or other senior officials to ensure the cell checks are being implemented in the manner prescribed. This is necessary to mitigate against the occurrence of further deaths in custody. In the event of non-compliance, the offending officers should be debriefed, sanctions imposed if necessary and corrective training required. 

19. Response 6- The SPS CCTV policy is governed by The Regulation of Investigatory Powers (Scotland) Act 2000 (RIP(S)A) requirements, meaning any access or review must be supported by a legitimate, proportionate and clearly evidenced purpose. The requirement for Governors or Senior Management to access this footage without such justification would fall outside the scope of its use.

20. The SPS has considered this recommendation, however for the reasons detailed above, does not accept this recommendation as it would not be deemed appropriate use of the SPS CCTV policy. As advised during the FAI, checks are undertaken by the Duty Governor at HMP Perth on a monthly basis in relation to unlocking procedures. In any SPS establishment, where it is determined that numbers checks have not been completed in accordance with SPS locking/unlocking processes, in addition to the application of performance management procedures, SPS Code of Conduct procedures can also be considered.

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