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 develop a standardised toolkit for auditing cells for the presence of ligature anchor points at HMP Barlinnie and use the toolkit to conduct an audit of potential ligature points within all standard cells.  Following from this audit, SPS should take steps to make standard cells at HMP Barlinnie safer by identifying and removing, as far as reasonably practicable, ligature points present in such cells.

3.    Response 1 - The SPS are currently working on the implementation of a ligature audit tool following a recommendation from another FAI determination. A proof of concept audit has been carried out, and during this it was recognised that the current audit tool (The Manchester Tool) is not sufficient in identifying the risk rating of the ligature anchor points within SPS cells. An external review has since been completed and a framework for ligature management within the SPS has been commissioned and is currently being progressed. The next steps involve reviewing and agreeing the ligature assessment process, alongside developing template documentation aligned with the national strategy. This process is ongoing and will provide SPS with the necessary tool to undertake such assessment as required by this recommendation for all SPS prisons. 

4.    A Ligature Reduction Solution Panel has been established within SPS, having one of its roles to evaluate any new furniture or fittings being placed in SPS cells, to ensure we do not introduce additional ligature points into cell accommodation. An interim process has been introduced during this transitional period which requires Senior SPS HQ based staff to review any maintenance replacements or where replacements within cell environments differ from the original specifications.

5.    Recommendation 2 - In cases where a prisoner has died by suicide, the DIPLAR process must consider how the prisoner was able to complete the suicide and consider the risks presented in the physical environment within which the death was completed.  Where a ligature has been used, the nature and availability of the ligature must be considered and details of it along with details of the anchor point used must be passed to estates for further consideration and action.

6.    Response 2 – DIPLAR is the SPS process for reviewing all deaths in custody and provides a system for recording any learning and identified actions. The SPS DIPLAR Guidance has been updated since Mr Sutherland's death, most recently in March 2025 following extensive consultation. The guidance now includes a requirement that, in cases where death has occurred by ligature, specific details are recorded within the DIPLAR paperwork. This includes the ligature point, the item used, as well as the location, cell type and overall condition. This ensures that the DIPLAR process gives due consideration to the safety and condition of the physical cell environment, including any damage, fixtures and fittings, and the availability of items that could potentially be used as a ligature. Other key updates were made to the guidance and template including the introduction of an Independent Chair being required for all DIPLARs, who will agree with those present if action points are to be local or national level. The Governor or Deputy Governor will also be required to attend to ensure they are content that the information recorded is accurate and as they have overall responsibility for any local actions arising.

7.    A recent Governors and Managers Action has been issued which aims to stop any new products, furniture or fittings which have ligature anchor points being placed in any SPS cells. A Ligature Reduction Solution Panel has been established, which includes evaluating any new furniture or fittings being placed in SPS cells. A reporting process will be implemented to ensure that the Ligature Reduction Solution Panel are advised of the ligature and anchor point for any death in custody where a ligature has been used for further consideration and action.

8.    Recommendation 3 – A national procurement exercise in relation to bedding should be carried out by the SPS.  The possibility of developing a bespoke product in collaboration with a supplier should be explored and an assessment conducted as to the feasibility of manufacturing bedding in house should be considered.

9.    Response 3 – As advised during the FAI and following a recommendation from another FAI determination, the SPS undertook a market research exercise in relation to alternative bedding materials for use across the prison estate in August 2025. SPS led comprehensive market research and engagement in consultation with the Ministry of Justice (HMPPS), Secure Care Providers, The State Hospital, SPS textile experts and textile laboratories and leading providers of bedding across the UK. While the research explored various bedding options to enhance safety for individuals in custody, it ultimately concluded that no currently available product offers a meaningful compromise between standard bedding and anti-ligature bedding that would be suitable to roll out across the SPS estate. SPS also engaged with in-house textile experts to assess whether a bespoke solution could be developed internally, however it was not feasible to produce a product that met the desired balance of safety and comfort using existing resources. The SPS remain committed to the monitoring of developments in the market and will continue to engage with innovation opportunities that may lead to effective bedding solutions in the future. 

10.    The SPS is moving forward with a procurement strategy in relation to producing standard bedding across the prison estate. A Project Team was established to oversee the programme of work and support the effective implementation of project deliverables. The Contract Management Team, alongside the Items in Use Short Life Working Group, is also undertaking a review of bedding stock, usage, and alternatives as part of wider demand management work. A procurement strategy was approved in April this year to establish internal workshops which will manufacture bedding items in-house, to provide consistent supply and quality. It is intended that this be progressed as a 12 month pilot of fully in-house manufacturing delivered through SPS Industries, with a view to subsequent long term implementation.

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