Section one Context Deaths in prisons in Scotland In August 2019, the conclusion of the Fatal Accident Inquiry (FAI) into the death of Mr Marshall following an incident at HMP Edinburgh was published. Allan Marshall, who was 30 years old, died on 28 March 2015 following continual physical restraint by multiple prison officers over a period of 40 minutes. The Sheriff presiding over the FAI found Mr Marshall had suffered from an episode of Excited Delirium Syndrome that resulted from him forcefully resisting the restraint, with the cause of death recorded as hypoxic-ischaemic brain injury due to out-of-hospital cardiac arrest during physical restraint on a man with coronary artery atheroma. The Sheriff concluded that the death was ‘entirely preventable’, with a number of missed opportunities in the days prior to and during the restraint, when prison officers could have made a decision to seek medical support from NHS Prison Medical Care Staff.60 Scotland’s Justice Secretary Humza Yousaf met with the family of Mr Marshall and told the media ‘they deserve an apology’.61 The conclusion of the FAI, four years on from the death, led to serious concern across the sector and brought further focus to the systems for responding to deaths in prison in Scotland. 60 61 62 The SHRC supported the Chief Inspector of Prisons in Scotland in her ongoing review into deaths in custody in Scotland, following an announcement made by the Cabinet Secretary for Justice in November 2019. The review will identify and make recommendations about areas of improvement to ensure that appropriate and transparent arrangements are in place in response to deaths in custody in Scottish prisons, including deaths of prisoners while in NHS care. Judith Robertson, Chair of the SHRC, is co-Chair of the review along with Wendy Sinclair-Gieben of HMIPS and Nancy Loucks from Families Outside (a charity which works on behalf of families affected by imprisonment). The review is examining the operational policies, practice and training in place within the Scottish Prison Service and NHS which are relevant to deaths of prisoners. It is intended to complement current arrangements for the investigation of deaths in custody and the holding of FAI, which are the responsibility of the Lord Advocate acting independently of any other person. The review follows the campaigning around failures of the current system from bereaved families. The final report of the review is expected to be published in 2021. In August 2019, Fatal Accident Inquiries: Follow up review was published by HM Inspectorate of Prosecution in Scotland.62 It looked at the progress three years on from the previous review (published in August 2016), and highlighted continued delays in hearings, which often take a number of years to be completed. The review made three new recommendations, including one about the prioritisation of FAIs on the deaths of young people in legal custody. Scottish Courts and Tribunals, August 2019, Fatal Accident Inquiry: Determination by Sheriff Gordon Liddle under the Inquiries Into Fatal Accidents and Sudden Deaths etc (Scotland) Act 2016 into the death of Allan Stewart Marshall, https://scotcourts. gov.uk/docs/default-source/cos-general-docs/pdf-docs-for-opinions/2019fai35.pdf?sfvrsn=0, [accessed 10/11/2020] BBC, September 2019, Justice secretary to apologise over Allan Marshall’s custody death, https://www.bbc.co.uk/news/ukscotland-edinburgh-east-fife-49608267 [accessed 10/11/2020] Scottish Government, August 2019, Fatal Accident Inquiries: follow up review, https://www.gov.scot/publications/followup-review-fatal-accident-inquiries/ [accessed 24/08/2020] 25