Source · Scotland · Fatal Accident Inquiry
Sarah Jane Riley
Scotland — FAI
Custody
8 recommendations
Reference [2025] FAI 42
Published 4 November 2025
Determination
| Reference | [2025] FAI 42 |
| Published | 4 November 2025 |
| Sheriff | Sheriff Pino Di Emidio |
| Sheriffdom | Tayside Central and Fife |
| Date of death | 12 January 2019 |
| Location | HMP Perth, Separation and Reintegration Unit |
| Cause of death | Asphyxiation (suicide) |
Recommendations 8
PDF
Scottish Ministers
SPS
Tayside Health Board
1. The Scottish Ministers and SPS should consider (a) establishing a system in respect of prisoners who have been sentenced to an OLR to allow for a psychological formulation focussed on the prisoner's risk to themselves, based on the information already available from the Risk Management Plan, to be prepared and shared with the prisoner's personal officer and other SPS and NHS staff working with the prisoner's personal officer on a regular basis; (b) providing training to SPS and NHS staff on the impact of OLR sentences on prisoners. 2. Training should be provided to SPS and NHS staff on OLR's and the impact of these sentences on prisoners. 3. The Scottish Ministers and SPS should consider (a) making a requirement that an urgent case conference should take place within 7 days of the arrival of a recalled prisoner who is within the scope of the current TSG policy to decide if the prisoner requires to be transferred to another prison; (b) specifying that the case conference should be chaired by a person of at least the rank of deputy governor; (c) the person chairing the case conference should be required to take action to secure that any decision as to transfer is actioned promptly; (d) the chair should within 7 days submit a report to SPS HQ detailing the reason for the decision of the case conference; and (e) the report should be considered forthwith by the most senior person on duty at the time it is received at SPS HQ. 4. Where an OLR or a TSG prisoner has been removed from association for more than 30 days for their safety, the Scottish Ministers and SPS should consider requiring that there should be an urgent high-level SPS HQ review at least at deputy governor level based on full reporting of the circumstances that has resulted in removal from association. 5. Where a prison has removed a prisoner from association without the prison staff having initiated the Rule 95 process timeously, the Scottish Ministers and SPS should consider making a requirement that the local prison should disclose the fact that the prisoner has been held in segregation without legal warrant to SPS HQ forthwith, and provide an explanation for the failure to apply within the correct timescale. 6. The Scottish Ministers and SPS should consider making a requirement that any request by a prison psychologist for the appointment of a personal officer to an OLR or TSG prisoner must be actioned within 7 days at deputy governor level. 7. The Scottish Ministers and SPS should consider making a requirement that: (a) a record should be kept of non-attendance by NHS staff at case conferences and the record monitored; and (b) if two successive case conferences are missed, this should trigger an obligation that a suitably experienced member of NHS staff must attend the next case conference. 8. The Scottish Ministers and SPS should consider making a requirement that when the need for a mental health assessment is identified on reception at prison or at a case conference or requested by a recently recalled OLR or TSG prisoner such an assessment should be commenced within 7 days.
No mandatory response mechanism — unlike PFD reports (England & Wales), recipients are not required to respond.
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About FAIs
Fatal Accident Inquiries are held under the
2016 Act
before a sheriff. They are mandatory for deaths in custody and at work.
The sheriff may make recommendations under s.26(1)(b) but there is no enforcement mechanism.