Recommendation 1: SFIU should implement monthly reconciliations of all active deaths investigations between SFIU National and the SFIU Divisions.
Recommendation 2: SFIU National should introduce a streamlined reporting/notification process for FAIs.
Recommendation 3: SFIU National should review, update and centralise all guidance and policies on the investigation of deaths.
Recommendation 4: COPFS should introduce an internal target for progressing mandatory FAIs.
Recommendation 5: Where criminal proceedings are instructed and the circumstances of a death require a mandatory FAI:
- COPFS should issue guidance requiring an instruction by Crown Counsel on whether a mandatory FAI is likely following the criminal proceedings; and
- COPFS should ensure there is a debrief between the team dealing with the criminal case and SFIU, at the conclusion of the criminal proceedings.
Recommendation 6: COPFS should ensure that all operational case related emails are recorded and imported into the case directory.
Recommendation 7: There should be a single point of contact for the nearest relatives throughout the criminal proceedings and any subsequent FAI.
Recommendation 8: SFIU National should explore with the Death Certification Review Service (DCRS), the possibility of the review service providing a consultative forum for SFIU to discuss medical cases.
Recommendation 9: COPFS should explore with the Scottish Civil Justice Council, the possibility of introducing rules to facilitate the attendance of “expert” witnesses at preliminary hearings to reach consensus on areas of agreement and identify areas of contention.
Recommendation 10: COPFS should provide a single point of contact for the nearest relatives in all FAIs.
Recommendation 11: SFIU should provide written notification to all participants on the issues COPFS intends to raise at the inquiry.
Recommendation 12: SFIU should agree a Memorandum of Understanding (MoU) with all investigative agencies that have responsibility to investigate the circumstances of certain types of deaths.