Just as an update on this, I have been doing some further testing.
I have 3 apps that have accessibility permissions granted (Button Mapper, Macrodroid & Map Speed Limit).
With all apps accessibility permission set to "on"

Then performing an ignition off then back on 2 out of the 3 loose the permissions but Button Mapper retains it

As far as I know I have the app settings the same for all three and have turned off the "Pause app activity if unused" toggle in the app settings for all of them.
I don't understand:
A) Why any of them loose permissions when it isn't a reboot just a sleep
B) Why Button Mapper retains it's permission but the other 2 don't
Any help on this gratefully received. Thanks