Death cases – A thematic report on liaison in death cases with particular reference to organ retention

A questionnaire was sent to all District Fiscals in Scotland with the aim of gathering information about liaison arrangements with next of kin which are currently in place in Fiscal Offices across Scotland in relation to deaths cases. A total of 31 replies were received and the results are presented in the following section. Not all questions have a total of 31 responses as the questionnaire used initially (information gathered between February and July 2006) was modified slightly. 9 responses were received to the original and 21 received in respect of a later version (information gathered between August and November 2006). The later version had an additional two questions which are highlighted in the analysis below. The responses to one further questionnaire are also included which was essentially a pilot (an earlier version of the original, data obtained in January 2006).

Due to rounding, percentages may not add to 100.

Communication and Liaison

We asked a series of questions aimed at finding out about the communication/liaison process between Fiscal staff and next of kin.

Fiscals were asked how they ascertain who the nearest relative contact person is in the deaths which are reported to their office. A total of 30 responses were received and all indicated that the information is obtained from the Standard Police Report. Many respondents indicated that if any clarification was required, this was usually sought verbally from the Police. The registrar's intimation was also mentioned as a source of information in this respect (albeit much less frequently). In non-Police cases indications were that the information was provided by and or sought from medical practitioners.

In relation to a question asking about the steps that are taken to ensure that translation and language needs are met in deaths cases a total of 30 responses were received. All responses indicated that the usual arrangements in relation to criminal cases for interpreting/translation needs would apply (5 of these noted that the need has never actually arisen). The majority (21, 70%) stated that initially notification from the police would be expected, usually via the Standard Police Report or verbally and then arrangements would be made by administrative staff re any needs which were highlighted therein. The remainder of the replies simply stated that they would use the services of the standard interpreting agencies as appropriate. Two of these indicated that they would contact the relevant consul if appropriate. Only three of all replies received explicitly stated that they would pursue enquiries with the Police if they suspected a need might exist which had not been flagged up in the Standard Police Report. One response indicated that the local hospital was good at informing the Procurator Fiscal (in cases involving hospital deaths).

A question was asked about the use of the "Checklist for Contact with Bereaved Relatives" (an aide memoire supplied by the Crown Office) and a total of 30 responses were received. The majority (21, 70%) indicated that staff did not make use of the checklist. Of those who stated that it was used and subsequently responded to a supplementary question, 6 out of 7 indicated that they did find it useful.

Similarly, Fiscals were asked if the "Advice for Bereaved Relatives" leaflet was issued in all cases where contact was made with the nearest relative. 29 responses were received and it was found that just over half of those (16, 55%) did issue the leaflet. 11 respondents (38%) indicated that they did not issue the leaflet in all relevant cases while another 2 revealed that it was not always issued. Those who responded negatively to the initial question gave a variety of answers as to what was done in place of issuing the leaflet. The most common response was that personal contact was made with the nearest relative (in preference to simply issuing the leaflet), either via telephone or the Police Family Liaison Officer. A few indicated that they gave the leaflets to other bodies for distribution (for example, undertakers, Police and GPs).

Fiscals were also asked if the information leaflet "Post Mortem Examination" was issued when an invasive autopsy was instructed. Of a total of 21 responses received, only one (5%) indicated that they did with another one respondent saying it was issued sometimes. The majority (17, 81%) revealed that they did not issue the leaflet. The remaining two respondents (10%) indicated that cause to issue the leaflet had never arisen.

Responses received (a total of 21) relating to how soon initial letters were sent to the nearest relative after the death report was received by the office revealed a fair amount of variation in response time. (The "target" is 2 to 3 weeks.) The results are summarised in the table below.

A related question enquired as to whether there were any local styles of letters used in addition to the standard Crown Office letters in communicating with relatives and pathologists. 29 responses were received and were fairly evenly split between those saying yes, there were local styles used (10, 35%), those saying no, there were not (11, 38%) and those indicating that adaptations of the standard letters were used (8, 28%).

"The … Department should answer complaints and queries in a much speedier time rate. All correspondence should be posted first class."

We asked Fiscals whether pathologists assist in relation to communication with relatives. All responses (a total of 31) indicated that if pathologists were required to assist they did/would do so. It was clear, however, that there was variation in the regularity with which input is required. Responses ranged from those which revealed that pathologists regularly attended meetings/spoke with relatives, to those indicating that this happened only very occasionally or that the need had not arisen. There was only one instance of a respondent indicating that pathologists were not as willing to assist as they used to be. Geographical location could obviously have an impact - one respondent revealed that this kind of practice was not really feasible for the islands but further indicated that they were confident that if the need arose it would be met. Where particular questions had arisen in the past they had been put to the pathologist by legal staff who then communicated with relatives. Shetland had in fact once held a telephone conference between the next of kin and the pathologist.

A series of questions then enquired as to the number and nature of deaths which had been reported to offices.

Firstly, we asked how many deaths had been reported in the previous 12 months which had required special consideration arising from religious and cultural considerations as required by the Book of Regulations. Of the 28 responses received the majority of offices indicated that there had been none (22, 76%). Two offices indicated that they had had one such death reported, while another two offices reported each having two deaths reported. A further two offices (Glasgow and Edinburgh) intimated that they could not be sure how many deaths they had had in this category as the IT system did not allow recording of such details. Glasgow reported dealing with around 2,500 deaths annually. It was easier for small offices which dealt with relatively few deaths generally, to identify (from memory) any requiring special consideration. We look at this in Chapter 8.

"The post mortem was against my mother's religion, as she was Jewish, however, I understood that it was part of the process and was happy for it to go ahead. I was able to bury my mother within 48 hours."

Secondly, we asked how many deaths were reported and investigated over the past 12 months where the ethnicity of the deceased was in some way related to the cause of death. This yielded a nil return from all 29 respondents save one (Glasgow) which again reported that it could not ascertain if they had any deaths in this category as the IT system did not record such details.

Lastly we enquired as to how many deaths reported and investigated had required organs to be retained. A total of 31 replies were received. Twenty of these (65%) indicated that they had had no such cases. Five offices indicated that they had had one case requiring organs to be retained; one office said they had had two cases, while another two offices stated that they had each had 3 such cases. One office noted 5. Again, Glasgow and Edinburgh commented on their inability to know how many cases there had been as these were not recorded by the IT system.

Organ Retention

Following on from this, we enquired as to whether the family was advised in writing of the possibility of organ retention and procedures for disposal. The 28 replies received were evenly split in this regard with 11 (38%) indicating that they did advise the family in writing and another 12 indicating that they did not. 6 respondents recorded 'non-applicable', presumably because they had no cases requiring organs to be retained over the past 12 months.

A supplementary question related to what was done by those who did not inform the family in writing. Of the 12 relevant responses 9 revealed that they enlisted the help of the Police Family Liaison Officer (usually done verbally) to notify the family. Two respondents said the family would be notified by telephone (a call from the Procurator Fiscal) and one indicated that the pathologist undertook to intimate and explain the procedure to the family.

"You have to think very carefully about retention if you want to retain and we go out of our way not to."

Fiscals were also asked whether they had procedures in place with pathology providers to let them know when organs had been retained and analysis was completed. The vast majority responded positively in this respect (30 out of 31, 97%) albeit one acknowledged that the procedures they have in place were informal. The one remaining office indicated that they had never had any cases where organs had been retained but they would nevertheless expect notification from the pathologist in any case.

A supplementary question then asked if the procedures in place were always followed - only one respondent indicated that there had been an instance recently when procedures had not been followed. It appeared that there had been a breakdown in communication between the Pathology Department and the Procurator Fiscal's Office which resulted in an unfortunate situation where the body of a deceased was returned to relatives without notification that an organ had been retained (this case is discussed more fully in Chapters 5 and 6). However, we understand that new procedures have subsequently been put in place which should prevent recurrence of such an incident.

We enquired also as to whether the release of organs for disposal was authorised in writing. While 21 out of 30 (70%) of respondents indicated that they did, a further 5 (17%) stated that although they had not had occasion to as yet, they would authorise the release of organs for disposal in writing if required. Three responses (10%) simply intimated that they had not had occasion to (no further information given). Only one respondent responded by saying no to this question, stating instead that the pathologist dealt with this issue.

Three Fiscals reported difficulties in relation to cases involving organ retention.

One office quoted the problem case referred to above.

Another office referred to 2 murder cases in 2005 where brains were retained. Retention, completion of neuropathology and return of organs to bodies was confirmed in writing by the mortuary. The bodies were then released apparently whole. Months later, the mortuary discovered two brains in a fridge. This resulted from miscommunication between the examining pathologist and mortuary technicians. The families were advised of the mortuary's error and instructions were sought and implemented re the disposal of organs. The mortuary subsequently revised its systems for ensuring the return of organs to a body, they now have a double entry system and the pathologist and technician both have to verify when an organ is retained and returned to the body before informing the Procurator Fiscal.

The final one referred to a case where problems had been experienced in relation to communication with the local hospital when there was no relevant staff available in the Procurator Fiscal's Office who could be contacted. This highlighted the fact that no fallback procedure was in place. The situation was a very urgent one as the hospital had switched off the life support machine.

Another office also raised a concern that the bereaved may incur additional costs to have the organs placed with the body at some later stage in the process.

"We ended up with two funerals."

We deal with organ retention in greater detail in Chapter 6.

Organ Donation

We enquired as to the number of deaths reported and investigated over the past 12 months that required approval for removal of organs for donation. Of the 30 responses received, the majority of offices indicated that there had been none (22, 73%). 5 offices (17%) indicated that they had dealt with such a case within the past 12 months with one of these having dealt with 3 cases. The other 4 responses gave no indication of how many deaths had actually been reported to their office. A further 3 offices indicated that they could not be sure as to whether they had had any cases, again because the system did not allow for recording of relevant details in this respect.

"There are good experiences with heart valves and corneas, there is a 72 hour window and they (Procurators Fiscal) are good at giving the ok quickly."

We asked Fiscals what practices they followed in relation to requests for organ donation in criminal and non-criminal deaths reported to them. 28 responses were received. 5 indicated that they had never had any such cases (hence no details were provided by these respondents). A further 12 respondents (43%) indicated that they would follow the Crown Office guidelines as laid down in the Book of Regulations in relation to requests for organ donation, albeit 3 indicated that was what they would do (they had not yet had any such cases). Generally, the other responses indicated that in non-criminal deaths, organ donation would be agreed to (although there was variation here in Fiscal involvement, with some saying they were not involved at all and some saying they discussed it with the pathologist and then approved the request). In respect of criminal cases, responses indicated that practice depended on the circumstances of the case but that wherever possible the request would be approved provided it did not compromise the forensic pathology, that any organs removed were not related to the death and guidelines were followed. One respondent mentioned canvassing the issue with Crown Counsel. Another respondent highlighted the fact that until recently they would not routinely have agreed to organ donation in criminal cases but the revised Chapter 12 in the Book of Regulations advised that this could be done provided all guidance was followed.

"So far as organ donation is concerned I know the transplantation teams always want more organs."

The Linlithgow Office revealed that Edinburgh Royal Infirmary Tissue Services had a mortuary donation programme where they sought permission for hearts to be retrieved for donation. The Procurator Fiscal had been notified of this and was asked for permission in Fiscal cases. Another separate programme being carried out by the Departments of Pathology, Forensic Medicine and Neuropathology at Edinburgh University sought consent from the Fiscal to approach the family of the deceased and ask if they could use diagnostic samples, take extra small samples and for the brain to be donated for research purposes. At Edinburgh Royal Infirmary, Tissue Services made the approach and discussed donation. Road Traffic deaths and suicide deaths were of interest to the Tissue Services - contact would be made with the Procurator Fiscal and he would consider the implication for the investigation.

The Glasgow Office supplied us with information on a recent homicide case where the cause of death had been a head injury. The hospital approached the Procurator Fiscal's Office for permission to take organs for transplantation. The family was apparently keen for this to be done. Contact was made out of hours with the on call Fiscal Depute and Crown Office gave consent to the taking of organs with the exception of the eyes. We understand that the organs taken were subsequently used in transplants. All this happened in the course of one day.

Staff Dealing with Deaths Work and Related Issues

We were interested to find out if Fiscal Offices had dedicated staff who dealt with deaths and organ related issues. 22 out of 30 offices (73%) indicated that they did have dedicated staff who dealt with this type of work. Of the 6 offices who stated that they did not, 2 were small offices where there was only a very small number of staff. Of the remaining 2 offices, one revealed that they used to have dedicated staff (the implication being that they did not any more) and the other that they have dedicated administrative staff but not legal staff.

"Day in and day out they (Fiscals) are asked to deal with bereaved people and are not prepared or trained."

Following on from the initial question we enquired as to how staff were selected for dealing with deaths and conducting sensitive discussions with relatives. A total of 30 responses were received. 12 (40%) cited experience as the determining factor for selection with 2 of these 12 also mentioning that this type of work was regarded as a development opportunity. Another of these 12 also detailed attendance at deaths training and familiarity with national guidance as factors. Another made reference to the fact that deputes' experience tended to be general rather than deaths-specific and since they had a high proportion of inexperienced deputes (as do a number of other offices) it was a challenge to adequately staff the post.

"That opens the question about help for those in the service who have to deal with highly stressful situations such as the above or attend particularly gruesome crime scenes. The emergency services have in place help for their staff, should we not for ours? It strikes me that we are ill prepared for many of the appalling sights we see and the deeply upsetting meetings we have with victims and relatives with no clear back up available."

Only one response stated that ability to deal with next of kin in a sensitive and appropriate manner was the sole basis on which staff were selected, although another respondent mentioned it as part of their criteria. A third of offices (10) indicated that selection was not relevant for them as they were such small offices that the deaths work was in all cases conducted by available legal staff (almost exclusively the District Fiscal). One office cited availability as the defining factor as all staff in the office were deemed sufficiently experienced to deal with such matters. A further 6 offices (20%) listed no specific selection criteria at all although 2 of these noted that legal staff are supervised initially. Another of these replies noted that there was no selection in their office due to the fact that only the District Fiscal and his Personal Assistant dealt with deaths cases.

Training

A question was also asked as to whether there was training and support available to staff with regard to dealing with bereaved relatives. Of 30 responses received a third indicated yes while almost two thirds (19, 63%) said there was no training available. One Fiscal indicated that there might be but had never enquired to find out.

"Training is needed for any staff dealing with next of kin and, in particular, specific training on the types of case they would have to deal with."

Fiscals were then asked to provide details of what this training involved and whether it was thought to be adequate. Of the 10 relevant responses 6 made mention of the Departmental deaths training with 4 of these making specific reference to the new training which was planned to accompany the revised Chapter 12 guidance. Another stated that although they felt what was available was reasonably adequate experience had shown it was extremely difficult to obtain training in this area. The remaining respondent quoted Crown Office guidance material which was available if required while also citing advice and guidance from senior colleagues as always being available.

Of the responses which had indicated no to the previous question one noted that training would be useful.

One Area Fiscal reported (separately) that he arranged for staff to "shadow" him and others before being allowed to handle this work.

Fiscals were also asked if their office provided any local training (for example, shadowing of an experienced member of staff). 23 offices (77%) out of a total of 30 responses indicated that they did, while 6 indicated that they did not. The remaining respondent indicated that local training was provided only if required.

We discovered that 17 out of 31 offices provided or contributed to training for outside bodies on the role of the Procurator Fiscal in relation to deaths. Of those who indicated that they did, most frequently, this involved contributing to junior hospital doctor training in local hospitals, GP surgeries and input to the Police. Also mentioned was training with Victim Support and the Witness Service as was an example of the District Fiscal contributing to/providing training for the Local and National Association of Funeral Directors. The Fiscal in Hamilton stated that he chairs a Lanarkshire Medical/Fiscal Liaison Group at which training issues are identified and dealt with.

While 13 respondents said that they did not contribute to training for outside bodies, 2 indicated that they are attempting to initiate this. The remaining office revealed that they had provided such training previously (but presumably no longer did so).

It appeared, however, that there was no external input into Fiscal training in the majority of instances (29 out of 31 responses). There were only 2 offices who responded positively - Hamilton, where arrangements had been made for new Deputes to attend post mortems and Dumfries which indicated that local pathologists and other medical staff are involved in training (no details given) and that there was locally organised training on death certification.

"Is it not time that more intensive training is given to staff dealing with deaths? Having to see relatives on a regular basis can be upsetting for staff, and as society becomes ever more a litigious blame culture these meetings become more and more fraught. If the NHS train staff specifically to break the news of organ retention should we be asking legal staff with no such training to break such news?"

With regard to the adequacy of Crown Office guidelines available to staff in the investigation of deaths, well over half (19, 66%) of Fiscals indicated that they were (of a total of 29 responses). 4 responded in the negative with another 3 saying that the guidelines were only partially adequate. A further 2 indicated that they were adequate but too lengthy/ cumbersome.

Comments received in relation to the adequacy of the guidance included the requirement for guidance on the conduct of Fatal Accident Inquiries, better clarification needed as to the types of deaths to be reported to Crown Office (children and Road Traffic deaths in particular) and the need for a checklist for each type of death.

Around a third (9, 29%) of Fiscals indicated that their office had local instructions over and above Crown Office guidance.

Victim Information and Advice ( VIA)

We asked Fiscals whether their office involved the services of Victim Information and Advice in deaths where proceedings were possible, where a Fatal Accident Inquiry was to be held or where significant further enquiries were required (ie in accordance with the criteria). Overwhelmingly, the answer was yes, in 29 out of 30 instances (97%). Only one office indicated that Victim Information and Advice was not involved. Of the 29, over half (16, 57%) said they found Victim Information and Advice's involvement useful. 5 (18%) indicated that they found the input very useful. One Fiscal remarked that the combination of the Police Family Liaison Officer and Victim Information and Advice was good and that it allowed the Fiscal to remain objective.

"( VIA was) very helpful and courteous."

Only 2 offices gave slightly negative responses in this respect - one where it was noted that Victim Information and Advice were unfamiliar with deaths liaison and preferred direct liaison between the District Fiscal and next of kin and another where it was felt that Victim Information and Advice involvement was not particularly useful until the case got to court. 3 offices reported that Victim Information and Advice's involvement was useful sometimes - 2 of these highlighted the fact that there could be an overlap between Fiscal/Victim Information and Advice roles and the possibility existed for too many people being involved. (Recent changes to the management structure of Victim Information and Advice should reduce the chance of this.) The third indicated that since generally next of kin were on islands they could have easier, regular and personal contact with the local Procurator Fiscal Office. The remaining two Fiscals reported that they were unaware of how useful Victim Information and Advice was as they had had little personal involvement with it.

"In those two trials the Witness Service was not involved that much, VIA was and the families were getting less support from VIA than they would have from the Witness service."

General Comments from Fiscals

• Training was needed - bereavement counselling would be good.

" COPFS should have a Bereavement Officer, separate from VIA."

• It would be beneficial to have guidance on how to contact relatives who live abroad.
• There was a real need for standardisation of practice, both on the part of crematorium medical referees and Procurator Fiscal staff in relation to deaths where, although there were no suspicious circumstances, the cause of death was unascertained. In practice this usually meant that the death was drug or alcohol related and that toxicological analysis of post mortem samples was required. Some referees were clearly content to accept such cases whereas others are not. The latter view, although resulting in practical difficulties, is consistent with Crown Office guidance. When difficulties arose the Fiscal was caught in the middle, relaying information between crematorium referees and pathologists/ GPs, in the interests of assisting the family. It would be beneficial therefore to have standardisation of crematorium practice on the one hand and clarification of the limits of the Fiscal's responsibility on the other. It seemed appropriate that any further information required by crematorium authorities with regard to the cause of death should be requested by them directly from the relevant GP or pathologist.
• The revised Chapter 12 and abbreviated Deaths manual were major improvements. The absence of an adequate search facility or index facility on the intranet reduced the user friendliness of these invaluable resources. Deaths investigation was an extremely important area of work. There was a need to have a post created centrally at senior level to co-ordinate the policy and practice of the Department in this area of work.
• There have been occasions when deaths had not been reported by the hospital.
• Perhaps more training was needed for doctors on certain categories of deaths to be reported to Fiscals. In one case, for example, the hospital doctor issued a death certificate without referring to the Fiscal but the consultant spotted this and referred the death.

"There is no joint training, we have not been asked. There have been no talks given in the hospital (by Procurators Fiscal) in the last few years."

• The categories of cases which required to be reported to Crown Office were not always clearly understood. The 12-week target for the holding of a mandatory Fatal Accident Inquiry was felt to be unrealistic as it was outwith the control of the Procurator Fiscal. Sometimes a court slot in order to meet the target was not available. There was also a query as to why a Fatal Accident Inquiry was necessary in some road traffic deaths where someone has been killed in the course of their employment eg when gales blew a lorry over or when driving too fast. It was argued that there should be some discretion.
• There had been problems getting independent expert advice within the constraints of current rules on payment of fees.
• For young Deputes (those who came straight from university with little life experience) bereavement counselling would be good. Also there should be greater familiarity with the options that are available to pathologists in terms of identifying causes of death. Training from pathologists would be useful.

In addition to the District Fiscal Questionnaires referred to above observations were made when examining the case records of approximately 400 deaths. ³ Some examples are as follows:

• Notes of meetings and discussions with nearest relatives, pathologists and Police were on file.
• Evidence was shown of the Procurator Fiscal taking account of nearest relative's particular wishes. In two deaths the widow and daughter requested that a post mortem was not done and after review of the death files a "view and grant" was instructed on both occasions. In one case a relative requested an early post mortem and this was done.

"The service, support and help that my wife and I were given from our arrival following the sudden death of my mother right through to the registration of death was absolutely first class."

• There was evidence of accommodating families' wishes regarding who the contact person should be (sometimes the "legal" next of kin would not have been appropriate).
• There was evidence of accommodating families who wished further enquiries by way of post mortem. There were two cases, one where there probably could have been certification but the widow was keen to have a post mortem to establish the exact cause of death as the deceased had been desperate to have a biopsy but was never well enough and another where the Police casualty surgeon was willing to certify but the spouse wanted a post mortem as he had concerns about treatment and there was a complaint against the NHS.
• Where appropriate there was fairly extensive contact with next of kin.
• Some Fiscals communicated with insurance companies assisting the next of kin.
• We found good evidence of close working relationships between pathologists and Fiscals in some areas of the country, including joint meetings with next of kin.
• One file showed that given the circumstances of the death the Procurator Fiscal had worked with others to try to get the doctor to certify the death. Another showed a successful attempt to have the Police casualty surgeon certify. There had not simply been recourse to instructing a post mortem.

"It would be good to see Fiscals taking a firmer stand on such cases and not accepting them."

• In another case the file showed that the initial contact letter had not been sent to the nearest relative due to her distressed state. The Procurator Fiscal liaised with the Police in this matter.
• There was evidence of the Procurator Fiscal taking account of more than one nearest relative. Examples included: ex-wife and fiancée; brother and wife; son and daughter; wife and parents; father and sister.
• Where appropriate we found that racial and cultural issues were taken into consideration when making decisions on how to proceed.
• Another case showed the Procurator Fiscal had considered the particular travel difficulties of the nearest relative in that he had offered to meet with this person in three different offices.

"I appreciated all the offers of help and the time the professionals gave me."

• In one case where there was the possibility of medical error or negligence and the post mortem would in the normal course of events have been carried out at the same hospital it was done at another forensic facility instead.
• In two cases letters of appreciation had been sent to the Procurator Fiscal from the next of kin.
• In another case there was a note on the file to say that the next of kin had phoned in and thanked the Procurator Fiscal and his staff for all their help.
• One family informed the Procurator Fiscal that they found it beneficial that their child had remained at the sick children's hospital to help them in their grieving process rather than the child being taken to a funeral directors.
• One file showed that the funeral had to be stopped because a junior doctor had certified the death and not reported it to the Procurator Fiscal when it later came to light that he should have.

As can been seen from the above findings legal staff appeared to be taking into account all the circumstances of the case when making decisions on how best to proceed with the death investigation and in communicating with relatives.

Although there were varying methods of contact with some Procurators Fiscal preferring initial oral communication, others preferring written and others using the services of the Police Family Liaison Officer, the majority of relatives were happy with the contact made with them and felt they were treated with courtesy and respect ( see Chapter 4).

Given the above findings and the results of the questionnaire analysis we consider that there are some areas that could be strengthened:

• With regard to maintaining an audit trail there were some areas of good practice that could be used throughout the whole of the Crown Office and Procurator Fiscal Service. For example, use of forms to record instructions to pathologists and to receive information from pathologists on retention and also use of a standard form to record the progress of work performed.
• In respect of the data retained in the computer system, it is considered that a field covering racial origin and organ retention/donation would be of benefit in carrying out future analyses and audits of such deaths.
• With regard to providing information to relatives some Procurators Fiscal always issued the appropriate leaflets whereas others did not ( see Chapter 4). We understand that the information leaflets are currently being revised. Once new leaflets are available Procurators Fiscal should be reminded to issue them where appropriate.
• We found that timing in communicating with nearest relatives varied from immediately to up to four weeks. This appeared to be dependent on the method of communication. The target for making initial contact is three weeks.

"Perhaps contact could have been made sooner."

• We also found that Fiscals use different styles of letters in communicating with relatives with some preferring the standard Crown Office letter whilst others preferring to amend these letters or have there own style.
• Larger offices tended to have a dedicated "Deaths Unit" and some Areas were setting up a centralised "Area Deaths Unit". This style should be considered for the whole of the Procurator Fiscal Service with a view to having dedicated, efficient, and well-trained staff.
• With regard to training we were informed that more external training would be useful in how to deal with bereaved relatives. It is therefore considered that further training would be of benefit not only to staff dealing with the issue but also the bereaved relatives.

We also sought input from staff on a general basis and a request for such was put out on the Crown Office Intranet.

One member of staff informed us a father had picked up a chair and threatened to kill him when he told him that his baby's brain would have to be retained. Fortunately the incident was resolved peaceably but is indicative of the depth of emotion such situations can cause.

In another case a family reacted badly to similar news and the staff member questioned whether Fiscal staff were best placed to break such news. Additionally he thought more training for staff dealing with such issues would be beneficial. On a similar theme he felt there was inadequate support for those staff who have to attend gruesome crime scenes, support being available for others involved.

Another contributor highlighted problems with cremation of organs following retention in a murder, the crematorium being apparently unable to cremate these when the body itself had not been cremated.

Overall, a positive picture emerged from the views of staff subject to the comments/ suggestions outlined. The investigation of deaths is an important but not very well known area of the work of the Procurator Fiscal. Training can obviously play a crucial part and we would strongly recommend the rollout of the Departmental training as soon as circumstances allow. Feedback from the "pilots" was good and although we were unable to assess for ourselves the training provided (due to cancellation of a course) we do not doubt that it will be beneficial.