Follow-up review of Fatal Accident Inquiries

Monitoring FAIs

31. All mandatory or discretionary FAIs or any complex deaths should be reported to SFIU National by the relevant geographical SFIU team dealing with the death investigation. This provides:

• An independent check on the progress of the case;
• An overview of timescales for completing investigations and holding FAIs; and
• An overview of the circumstances of all FAIs.

32. In the thematic report we found:

33. There were differing approaches to monitoring and reporting cases in the three geographical teams – they did not routinely inform SFIU National of mandatory FAIs or cases where a discretionary FAI was being considered until late in the investigation when a report was sent seeking Crown Counsel's instructions (CCI).

34. The six week target for reporting cases to SFIU was routinely not met by any of the SFIU teams often due to relevant information such as the post mortem report not being available.

35. There was no formal reconciliation of information held by SFIU teams and SFIU National.

36. Guidance on the investigation and reporting of deaths was out of date and often circulated by email which was of little assistance to new members of staff or where there had been a change in personnel.

We recommended:

1) SFIU National should introduce a streamlined reporting/notification process for FAIs.

2) SFIU should implement monthly reconciliations of all active deaths investigations between SFIU National and the SFIU Teams.

3) SFIU National should review, update and centralise all guidance and policies on the investigation of deaths.

Action Taken

Recommendation 1

37. A streamlined process for reporting deaths to SFIU National was introduced in October 2018. The heads of the geographical teams are responsible for completing an abbreviated form (known as an eF1), replacing the more detailed first stage report, notifying SFIU of deaths where:

• a mandatory FAI is required;
• a discretionary FAI may be instructed; and
• any death which is complex, unusual, high profile or may attract media attention.

38. If the case preparer wishes to seek guidance from SFIU National or Crown Counsel in relation to an ongoing investigation then s/he can report by way of the more detailed First Stage report.

39. The guidance issued states that the eF1 should be saved in the case directory and a copy sent to SFIU National electronically where they are recorded on a master spreadsheet.

40. The process provides for early intimation of mandatory/potential discretionary FAIs and more complex cases.

41. We found that such cases were being intimated to SFIU by emailing the eF1 form which was then entered onto a spreadsheet. However, contrary to the guidance the forms are not being saved in the electronic case directory and within the email account they are not categorised in a systematic manner; some have the procurator fiscal office reference number; others the name of the deceased; and others have no identifying characteristics in the subject heading of the email.

42. Historically death cases were not recorded electronically and we were advised that the culture in the SFIU teams is to save documentation in a shared drive in SFIU folders or in hard copy papers rather than in the electronic case directory. This reflects what we found in this review. It results in information relating to a death being retained in different places and in different formats making it difficult to have an overview of the investigation. It is also out of step with the way COPFS operates in all other areas of its business.

43. Within SFIU, there is an ongoing modernisation project with a number of work streams, headed by a senior legal manager. One work stream is to ensure that all documentation is recorded in the case directory. Where we did find evidence of some documentation being scanned into the case directory, it did not conform to standard naming conventions^[36] making it difficult to identify what was there without opening all of the documents, a cumbersome process.

Status: In progress

Recommendation 2

44. All FAIs are recorded on a COPFS IT system known as the Management Information Book (MI Book) and, as discussed above, the heads of the SFIU geographical teams report all mandatory and potential discretionary FAIs through the eF1 process. A designated person within SFIU National undertakes a monthly reconciliation between those recorded on the MI Book and those reported by the eF1 process.

Status: Achieved

Recommendation 3

45. This is also being progressed as a work stream within the SFIU modernisation project. It aims to produce a one-stop-shop of guidance contained in a SFIU Manual of Practice.

46. It is anticipated that it should be completed by December 2019 following slippage of the initial target to complete the manual by April 2019.

Status: In Progress

New Recommendation

To provide a clear audit trail in each case the work stream to record all information in the case directory should be prioritised and documents should be recorded and named in a structured manner.