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Form 6.2 RESPONSE SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH Court ref: EDI-B36-24 DETERMINATION OF SHERIFF RODERICK FLINN UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC (SCOTLAND) ACT 2016 in the inquiry into the death of WILLIAM LOTHIAN To the Scottish Courts and Tribunals Service 1. The Scottish …
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Form 6.2
RESPONSE
SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH
Court ref: EDI-B36-24
DETERMINATION OF SHERIFF RODERICK FLINN
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC
(SCOTLAND) ACT 2016
in the inquiry into the death of
WILLIAM LOTHIAN
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 – The reception process should be reviewed by SPS at the earliest
convenient opportunity (and if possible within the scope of the current review of prevention of
suicide policy) with a view to considering whether there should be an automatic referral to the
Talk to Me process where a new prisoner is a first time offender, an offender convicted of a
sexual offence (or other offences which carry an increased risk of suicide and an individual
with a history of one or more suicide attempts;
3. Response 1 – The review into the SPS Suicide Prevention Strategy, also known as Talk to Me
is ongoing and is expected to be completed by Summer 2025. The strategy development and
implementation phases will commence thereafter. Crucial to the review will be the
consideration of the lessons learned from various reports including Fatal Accident Inquiries.
The recommendations put forward in the Mr William Lothian FAI will form part of the review
consideration. This will include a review of the reception process and consideration will be
given in relation to whether there should be an automatic referral to Talk to Me for all relevant
risk factors such as the individual’s offence details, any known historic suicide attempts and
whether this is their first time in custody.
1
4. Recommendation 2 - The Reception Risk Assessment Form should be reviewed by SPS, at
the earliest convenient opportunity (and if possible within the scope of the current review of
prevention of suicide policy) with a view to considering whether the following should be added:
(a) a specific record of whether the new prisoner is a first time offender, an offender convicted
of a sexual offence (or other offences which carry an increased risk of suicide) and/or an
individual with a history of one or more suicide attempts;
(b) a note for the guidance of SPS staff within the form that these factors, taken together, may
indicate a higher risk of suicide than the norm;
(c) provision for the recording of factors relating to the specific consideration of risk in respect
of gender, age, evidence of chronic and disabling physical illness, evidence of drug or alcohol
misuse, evidence of social isolation, evidence of assessment of the prisoner’s mental state,
evidence of hopelessness, worthlessness, and feelings of guilt and/or unworthiness;
(d) a requirement for SPS staff to document the actions taken by staff following identification
of such risk factors, or the rationale for not taking any action.
5. Response 2 – The review into the SPS Suicide Prevention Strategy, also known as Talk to Me
is ongoing and is expected to be completed by Summer 2025. The strategy development and
implementation phases will commence thereafter. Crucial to the review will be the
consideration of the lessons learned from various reports including Fatal Accident Inquiries.
The recommendations put forward in the Mr William Lothian FAI will form part of the review
consideration. This will include a review of all relevant Risk Assessments such as the Reception
Risk Assessment Form. Points (a) to (d) of this recommendation will be considered under this
part of this review.
6. Recommendation 3 - The reception process should be reviewed by SPS and Lothian Health
Board at the earliest convenient opportunity (and if possible within the scope of the current
review of prevention of suicide policy) with a view to considering whether it is feasible to
establish a system for automatic referral to the prison’s Mental Health Team, based on an
established set of criteria.
7. Response 3 – The review into the SPS Suicide Prevention Strategy, also known as Talk to Me
is ongoing and is expected to be completed by Summer 2025. The strategy development and
implementation phases will commence thereafter. Crucial to the review will be the
consideration of the lessons learned from various reports including Fatal Accident Inquiries.
The recommendations put forward in the Mr William Lothian FAI will form part of the review
consideration All relevant NHS Health Boards will be involved as key partners in this review
2
as well as the strategy development and implementation phases. Consideration will be given,
in conjunction with all relevant NHS Health Boards, as to the feasibility of establishing a system
for automatic referral to the prison’s Mental Health Team as part of the reception process.
3
RESPONSE
SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH
Court ref: EDI-B36-24
DETERMINATION OF SHERIFF RODERICK FLINN
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC
(SCOTLAND) ACT 2016
in the inquiry into the death of
WILLIAM LOTHIAN
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 – The reception process should be reviewed by SPS at the earliest
convenient opportunity (and if possible within the scope of the current review of prevention of
suicide policy) with a view to considering whether there should be an automatic referral to the
Talk to Me process where a new prisoner is a first time offender, an offender convicted of a
sexual offence (or other offences which carry an increased risk of suicide and an individual
with a history of one or more suicide attempts;
3. Response 1 – The review into the SPS Suicide Prevention Strategy, also known as Talk to Me
is ongoing and is expected to be completed by Summer 2025. The strategy development and
implementation phases will commence thereafter. Crucial to the review will be the
consideration of the lessons learned from various reports including Fatal Accident Inquiries.
The recommendations put forward in the Mr William Lothian FAI will form part of the review
consideration. This will include a review of the reception process and consideration will be
given in relation to whether there should be an automatic referral to Talk to Me for all relevant
risk factors such as the individual’s offence details, any known historic suicide attempts and
whether this is their first time in custody.
1
4. Recommendation 2 - The Reception Risk Assessment Form should be reviewed by SPS, at
the earliest convenient opportunity (and if possible within the scope of the current review of
prevention of suicide policy) with a view to considering whether the following should be added:
(a) a specific record of whether the new prisoner is a first time offender, an offender convicted
of a sexual offence (or other offences which carry an increased risk of suicide) and/or an
individual with a history of one or more suicide attempts;
(b) a note for the guidance of SPS staff within the form that these factors, taken together, may
indicate a higher risk of suicide than the norm;
(c) provision for the recording of factors relating to the specific consideration of risk in respect
of gender, age, evidence of chronic and disabling physical illness, evidence of drug or alcohol
misuse, evidence of social isolation, evidence of assessment of the prisoner’s mental state,
evidence of hopelessness, worthlessness, and feelings of guilt and/or unworthiness;
(d) a requirement for SPS staff to document the actions taken by staff following identification
of such risk factors, or the rationale for not taking any action.
5. Response 2 – The review into the SPS Suicide Prevention Strategy, also known as Talk to Me
is ongoing and is expected to be completed by Summer 2025. The strategy development and
implementation phases will commence thereafter. Crucial to the review will be the
consideration of the lessons learned from various reports including Fatal Accident Inquiries.
The recommendations put forward in the Mr William Lothian FAI will form part of the review
consideration. This will include a review of all relevant Risk Assessments such as the Reception
Risk Assessment Form. Points (a) to (d) of this recommendation will be considered under this
part of this review.
6. Recommendation 3 - The reception process should be reviewed by SPS and Lothian Health
Board at the earliest convenient opportunity (and if possible within the scope of the current
review of prevention of suicide policy) with a view to considering whether it is feasible to
establish a system for automatic referral to the prison’s Mental Health Team, based on an
established set of criteria.
7. Response 3 – The review into the SPS Suicide Prevention Strategy, also known as Talk to Me
is ongoing and is expected to be completed by Summer 2025. The strategy development and
implementation phases will commence thereafter. Crucial to the review will be the
consideration of the lessons learned from various reports including Fatal Accident Inquiries.
The recommendations put forward in the Mr William Lothian FAI will form part of the review
consideration All relevant NHS Health Boards will be involved as key partners in this review
2
as well as the strategy development and implementation phases. Consideration will be given,
in conjunction with all relevant NHS Health Boards, as to the feasibility of establishing a system
for automatic referral to the prison’s Mental Health Team as part of the reception process.
3