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

The Inspectorate seeks to make recommendations which will improve service delivery and takes wherever possible a "user perspective". Any conclusions/recommendations must be evidence based rather than conjecture.

The area of investigation of sudden deaths posed particular problems in ingathering evidence. Clearly causing further distress to those recently bereaved was to be avoided especially those bereaved in circumstances which necessitated the death being referred to the Procurator Fiscal.

However, without some first hand input any conclusions/recommendations could only be tentative. Consequently we decided among other ways of ingathering evidence to examine a significant number of death cases reported to Procurators Fiscal throughout Scotland and send questionnaires to those identified as the next of kin or contact person.

Accordingly 400 cases were examined in Procurator Fiscal Offices throughout Scotland to get as wide a geographical spread as possible and covering all categories of deaths from non-suspicious deaths to suicides, murders, accidents at work, road traffic collisions etc.

"I was very satisfied with the information I got."

Cases were examined in a number of locations including Grampian, Ayrshire, Strathclyde and Lothian and Borders. 200 were identified from the sample as being suitable for the survey and a questionnaire sent out. The letter accompanying the questionnaire was carefully drafted to try to minimise any distress and promised anonymity. Victim Support Scotland was consulted in advance of sending the questionnaire.

A high percentage of replies were received. 72 people replied (36%) out of the 200. This is a high rate of return compared to other surveys and the Inspectorate is very grateful to those who took the trouble to reply at what must have been a difficult time in their lives.

The questionnaire was designed to be sufficiently brief to encourage completion and was a mixture of questions inviting a yes/no answer and space for some general comments. The questions were designed to elicit a general picture of the perception of the user of the service provided by the Procurator Fiscal. Ideally it would have been much more detailed but response rates would probably have suffered as a result.

As has been described previously a wide variety of deaths are reported to the Procurator Fiscal some requiring more investigation than others including carrying out a post mortem examination and possible changes to initial death certificates. The range of deaths chosen in the sample reflects the diverse nature and complexity of deaths reported to the Procurator Fiscal.

The following is a question by question analysis of the results. It should be noted that not all questions were answered by every respondee.

Question 1

Did you receive any written communication from the Procurator Fiscal?

Of the 66 people who answered 45 (or 68%) said they had received written communication from the Procurator Fiscal.

It should be noted that the Procurator Fiscal has a certain degree of discretion as to how to contact the nearest relative, if at all. A number of cases may be reported to the Procurator Fiscal which are dealt with by relatively speedy initial enquiry and no further investigation is required and it would not be usual for the Procurator Fiscal to have any contact with the nearest relative in such cases unless contact had been initiated by them.

"The Procurator Fiscal phoned me to let me know the death certificate had been released and asked would I like to know what was the cause of her death."

Our survey deliberately targeted people who had had some contact with the Procurator Fiscal so cases where the Fiscal had not needed to contact the nearest relative do not feature in our survey. This was done to save distress to people who had not been contacted in case our questionnaire suggested to them that something had been missed in the investigation of their relative's death which would not have been the case.

Question 2

Did you receive any verbal communication from the Procurator Fiscal?

Of the 66 who answered this question 48 (or 72%) said they had received verbal communication. 34 of the 66 who responded to these questions had received both written and verbal communication (or 51% of the total).

Of those who had received only one form of communication which was 26 in total this was evenly split between verbal (12, or 17%) and written (14, or 20%).

Question 3

Did you receive any information leaflets?

Of the 65 persons who answered this question only 19 said they had received any information leaflets (or 29% of the total). On the face of it this seems quite a small percentage.

Instructions to Procurators Fiscal state that:

"in all cases where the Procurator Fiscal has had contact with the nearest relative/family they should be sent the general information leaflet 'Advice for Bereaved Relatives'.

This is designed to provide basic essential information to families in the immediate period following a sudden death. The Book of Regulations recognises that at this stage in bereavement many relatives do not want to receive detailed information but that it is important to provide a contact point so that further information can be sought by those who require it at a time when they are able to deal with it.

Given that contact had been made in 64 out of the 68 responses we received this figure for sending the leaflet is fairly low and suggests underuse of the Departmental leaflet.

However, having said that it is important to take into account the answers to the next question.

Question 4

Did you receive all the information you required?

Of the 64 who answered this question 54 (or 84%) said that they had received all the information they required. This is particularly significant for the Department especially in view of the relatively small number of cases where the leaflets were sent out. It tends to suggest that the written or verbal contact made by the Procurator Fiscal was sufficient for the purposes of the nearest relative. It shows a very high level of "customer" satisfaction on this arguably most important part of death investigation. There were, however, a few exceptions.

"I felt totally in the dark regarding the post mortem. I only received a 30 second phone call from the Procurator Fiscal's Office. I would have found someone to liaise with a great help."

Question 5

Were you treated with courtesy and respect?

59 of the 68 respondents specifically answered this question and said 'yes'. No respondent answered 'no' (one respondent was slightly ambivalent, the explanation provided indicating it had more to do with coping with grief than the manner in which the respondent had been treated).

"The help and sympathy were exceptional. All concerned could not have been more helpful."

Given the difficult circumstances of such work and the stress relatives are suffering this is reassuring information for the Department. Even those who answered other questions in a more negative fashion (including those who said they did not get all the information they required) answered "yes" to this question.

Clearly it would be expected that people would be treated with courtesy and respect but nevertheless this is a resounding endorsement of the manner in which the Department deals with relatives.

Question 6

Did you have any contact with Victim Information and Advice ( VIA) Division?

Only 4 of the 39 respondents who specifically answered this question said they had had any contact with VIA (10%). Those who did not specifically answer the question are of course likely not to have had any contact either. The figure is surprisingly low but the remit of VIA in death cases is strictly limited.

"It was a relief to have contact with the VIA Division."

Certain categories of deaths are automatically referred to VIA for a full VIA service to the family and these are murder, other homicides, definite or suspected Road Traffic Act Section 1/3A cases, Section 3 cases, Road Traffic Act cases in which no criminal proceedings are being taken, accidents at places of work in the course of employment, child deaths and deaths identified as potential discretionary Fatal Accident Inquiries. Deaths in the following categories may be referred to VIA subject to discussion and agreement between the relevant Procurator Fiscal and VIA staff and these include drug related or solvent abuse, suicide, drowning, medical negligence and deaths in custody.

It should be noted that within the past 12 months the management structure of VIA has been reorganised and it no longer operates as a separate division within Crown Office and the Procurator Fiscal Service. Area and District Fiscals now have responsibility for the management of the VIA staff in their areas. This provides a better opportunity for more focused work in this area.

Question 7

Any further comments?

We invited respondents to suggest improvements/comments. 32 of the 68 respondents took the trouble to add some comments.

• 13 of these were testimonials to the helpfulness etc of the Procurator Fiscal and Crown Office staff.

"Can't think of any (ie improvements) for you as all the service I received was great. Many thanks for all you did."

• 5 complained about delays in getting information, one complained that a post mortem examination which had taken place had been unnecessary.

"Explain to parents the need for an autopsy and obtain approval before it is performed. I feel the autopsy was an unnecessary violation/invasion of his body."

• 1 was a complaint about the medical emergency services.
• 2 felt that the deaths were being treated as statistics including mis-spelling of the deceased's name on a file.
• Another concerned mistakes in correspondence.
• A further respondent said they had felt left out of things although the "family" had kept them informed.
• Another complained about having to write for a copy of the post mortem report.
• In another case there was a complaint that the medical notes had not been present at the time of the post mortem causing an apparent later change in the cause of death given by the pathologist.
• Another related to a complaint about access to a body after a death in an institution.
• One related to a lack of support for families of missing persons later discovered to be suicide.
• One suggested information on support groups would be useful (a suicide).
• Another suggested feedback following a post mortem to the hospital consultant who had carried out a procedure two days earlier.

In addition to the Questionnaire contact was made with a number of support organisations.

The Stillbirth and Neonatal Death Society ( SANDS) made some comments. In particular it was highlighted how reluctant many people felt with regard to post mortem examination and the hurt that unknown retention (of organs) could cause.

"The problem was with the heart, it had been used for teaching for 13 years."

On the other hand we were told how altruistic families could be in difficult circumstances.

"I don't have a problem with it (retention) now. I see it as a positive thing."

"If we had not had a post mortem we would not have known what was wrong."

The importance of early contact with families was also emphasised.

"Time is the worst and they can probably do nothing, just inform you that some of the tests will take 12 weeks."

The organisation Families of Murdered Children ( FoMC) made some comments.

"For 10 years we have been pushing and there is progress being made."

FoMC volunteers provide court support and liaise with the Procurator Fiscal Service on behalf of families. The group has been in existence for 10 years and supported, in various ways, 700 families worldwide.

"In 100% of murder cases the victim's family want their day in court even if the accused walks out of it. People would prefer that the accused walked than a plea to a reduced charge."

In 10 years FoMC feel that they have seen changes for the better:

• The introduction of Police Family Liaison Officers
• The introduction of Victim Information and Advice
• Most prosecutors will now speak to the family and that made a difference
• Prosecutors giving warning of when they intend to lead possibly distressing medical evidence.

"All in all it is quite good."

They would like some improvements, however:

• Improved communication with nearest relatives and smoother handover from Victim Information and Advice to the Witness Service
• For Victim Information and Advice not to be subsumed into the Fiscal Service
• Clarification of the role of Victim Information and Advice.

We also met with a number of nearest relatives as a result of our postal survey and an advertisement placed in a national newspaper.

In one case both relatives spoke of the kindness and helpfulness of the Fiscal.

"The Fiscal gave us peace of mind."

We were told a written pamphlet would have been useful but these relatives got as much information from the Fiscal as they needed.

On the other hand in another case the nearest relative was dissatisfied with the manner of the Fiscal and also with the Police and the hospital concerned.

In another, the nearest relative again stressed the grief caused to her by the unknown retention of organs.

"I don't know how I am supposed to get any closure on this by just being told it was practice at the time."

Our final contributor also stressed the hurt caused by undisclosed retention.

"It goes on and on and it hurts so much to have to try and deal with this, it is soul destroying."

The changes which have taken place (particularly regarding organ retention) since the experience of these contributors should hopefully make such comments unlikely in the future.

Overall, the feedback from system users was fairly positive again subject to the comments/ observations made.