Suicide prevention is at the heart of our work to keep people in custody safe. It is a central focus of the Fatal Accident Inquiry (FAI) recommendations and the lessons learned from deaths in custody.

A key priority in this area is the overhaul of Talk to Me – our crisis response policy for individuals at risk of suicide. This policy plays a vital role in identifying, supporting, and protecting those who are most vulnerable.

The FAIs have highlighted important areas for improvement in how Talk to Me is applied in practice. We are acting on these findings to ensure the policy is not only robust but consistently implemented across all settings.

As part of this overhaul, we are also taking into account relevant recommendations from other FAIs to strengthen our approach and embed best practice. Our goal is to create a system that is compassionate, responsive, and effective in preventing suicide.
 

Concern phoneline implementation

Status: Complete

Recommendation 9∆

In February 2024 we implemented dedicated 24-hour concern phonelines for each of our prisons, strengthening the routes to raise a concern for the mental health of someone in custody.

Phone numbers are available on each prison's web page, and our dedicated 'Raise a Concern' page also details what action our staff will take following receipt of such information. 

Recording issues of concern

Status: Complete

Recommendation 14 (viii)∆

Guidance has been issued to staff regarding the revised process for processing and recording a communication of concern from an external caller, which includes family, friends and other external criminal justice partners.

Further guidance was also issued in relation to the use of concern forms, to record any concerns they may have about a person in custody's welfare or safety.

DIPLAR process review

Status: Complete

Recommendation 3☐ and 15∆

We have undertaken a lessons learned exercise, and reviewed the Death in Prison Learning Audit & Review (DIPLAR) process for deaths in prison custody. Further to this, DIPLAR chairs have been appointed to cover all DIPLARs.

Revision of Talk To Me and MORS policies and guidance

Status: In progress

Recommendation 14 (i-vii)∆

We are currently undertaking a full overhaul of the Talk to Me policy and guidance. Central to this overhaul will be a stronger emphasis on recognising wider risk factors, such as substance misuse, that contribute to vulnerability. 

Work has also commenced to review our Management of an Offender at Risk due to any Substance (MORS) policy, which will consider the Talk To Me review to ensure alignment of policies and processes.  

The overhaul of Talk To Me is well underway. Policy guidance has been amended to ensure all young people are under observation for their first 72 hours in custody following admission, and until such time as a case conference assesses all suitable information is held to remove them from observation. This is now in place at HMP & YOIs  Polmont and Stirling, and HMP & YOI Grampian has been made aware as an additional precaution.

A greater number of observation cells are now operational in HMP & YOI Polmont, with an evaluation of their effectiveness to take place in 2025.

Talk To Me independent review

Status: In progress

Recommendation 14 (l-xi)∆

The Talk To Me independent review concluded its listening and learning phase in July. The review team shared their draft report with us at the end of August for internal fact checking, and a final report was received at the end of September with publication planned for late 2025.

This timeline aligns with the commitment made to the Court following the FAI, which stated that the review would be completed by the end of the summer, a deadline both we and the reviewers fully expect to meet.

Development of suicide prevention pathway

Status: In progress

Recommendation 14 (l-xi)∆

We will publish a document setting out our suicide prevention pathway and our long-term intent to reduce suicide in prison by the end of 2025.

Pilot of suicide prevention pathway

Status: In progress

Recommendation 14 (l-xi)∆

Our new suicide prevention pathway will be piloted to test its effectiveness while full scale training packages are developed. It is expected that this will take place from early 2026. 

Further phases of the pathway will focus on health and wellbeing interventions and work to develop a self-harm pathway.