Thematic review of Fatal Accident Inquiries

1. Section 26 of the Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016.

2. Black v Scott Lithgow Limited 1990 SLT 612 per the Lord President (Hope) at p 615G-H.

3. The Act received Royal Assent on 14 January 2016. Sections 36(6), 40, 41, 42 and 43 and schedule 1 came into force on the day after Royal Assent. The remaining provisions come into force on a date to be appointed by Scottish Ministers.

4. Recommendations 12 to 17.

5. The majority of provisions will commence on a date appointed by the Scottish Ministers.

6. Section 36 of the Act.

7. Section 2 of the Act.

8. Section 3(1), (2)(a-e) of the Act.

9. Section (4) of the Act.

10. The preliminary hearing is a procedural hearing. The purpose is to adjudicate on the state of preparation of the participants to the inquiry and resolve any outstanding issues prior to the inquiry. Detailed rules to accompany the Act will provide guidance on how preliminary hearings will operate in practice.

11. Sample taken from all concluded FAIs, where a preliminary hearing was held between 2012/13 to 2014/15, representing 100% of all discretionary FAIs (18 cases) and 54% of all mandatory FAIs (70 cases).

12. Between 2012/13 and 2014/15.

13. COPFS Strategic Plan 2015-2018.
http://www.crownoffice.gov.uk/images/Documents/Business_Strategy_Plans/Strategic_Plans/COPFS%20Strategic%20Plan%202015-2018%20.pdf

14. Coroners Statistics 2014, England and Wales, Ministry of Justice Statistics bulletin.
https://www.gov.uk/government/statistics/coroners-statistics-2014

15. Source - COPFS MI Book 31/05/16.

16. A certificate specifying the cause of death required to enable registration of a death with the Registrar of Births, Deaths and Marriages in Scotland.

17. Source - COPFS MI Book 31/05/16.

18. Source - COPFS MI Book 31/05/16.

19. Source - COPFS MI Book 31/05/16. Note: The total does not always add up to 100% due to a delay in inputting target data.

20. Some FAIs may involve multiple deaths.

21. Source - SFIU spreadsheet 11/11/15 (based on first Preliminary Hearing date).

22. Between 2012/13 and 2014/15.

23. Source - SFIU spreadsheet 11/11/15, based on first Preliminary Hearing date.

24. From March 2015 GPs submit reports electronically.

25. The Law Officers (Lord Advocate and Solicitor General) and Advocates Deputes.

26. Source - COPFS MI Book 31/05/16.

27. Source - COPFS MI Book 31/05/16.

28. The 1976 Act requires an application to hold a FAI to be made to a sheriff, narrating briefly the circumstances of the death.

29. Source - SFIU FAI database 18/05/16.

30. In four cases there was no post-mortem and in two cases the date the post-mortem report was received was unknown.

31. Section 14 of the Act.

32. 18 cases.

33. 70 cases.

34. Of the 35 mandatory FAIs related to death in employment, eight were investigated by HSD.

35. SFIU database at 5/11/15

36. 88 cases.

37. 75 cases (13 cases were assessed as having a substantial criminal investigation).

38. 27 cases (of the 35 work-related deaths, eight were progressed by HSD and are recorded under ' HSD' heading).

39. Three cases did not have a PH.

40. 35 cases.

41. Nine cases (eight work-related deaths and one discretionary).

42. There was no PH in one case.

43. 17 cases (One was progressed by HSD and is recorded in the HSD heading).

44. 13 cases were assessed as having a substantial criminal investigation.

45. Excludes nine HSD cases as they were not progressed by SFIU.

46. 79 cases, of which 10 were assessed as having a substantial criminal investigation.

47. 69 cases.

48. Seven cases.

49. Two cases did not have a preliminary hearing.

50. 38 cases of which nine had substantive criminal investigations.

51. 34 cases of which one had substantive criminal investigation.

52. One case did not have a preliminary hearing.

53. Five cases.

54. 47 cases - Includes: 13 discretionary FAIs (1 was dealt with by HSD and 7 involved a criminal investigation) and 34 mandatory FAIs (8 were dealt with by HSD of which 3 involved a criminal investigation).

55. 34 cases - 16 mandatory deaths in custody and 18 mandatory deaths while in employment.

56. 5 cases - 2 mandatory deaths in custody and 3 mandatory deaths while in employment.

57. Excludes cases involving a substantial criminal investigation.

58. A document setting out agreed uncontroversial facts.

59. 62 cases.

60. HSD cases are discussed at page 47.

61. Section 3(1) of the Act.

62. Including nearest relatives, employers in two instances, a manufacturer, and DVLA.

63. Included two cases where there was a substantive criminal investigation.

64. Calculation relates to 28 cases. In two cases there was no data available on the dates reports were instructed or received.

65. Section 15 of the Act.

66. Those entitled to be represented has been extended in the new Act.

67. 15 cases.

68. Justice Committee Meeting report. Columns 21/22 (page 15), 26 May 2015.
http://www.parliament.scot/parliamentarybusiness/report.aspx?r=9969&mode=pdf

69. NHS boards carry out "adverse event reviews" where there are concerns about the circumstances of a death.

70. Healthcare Improvement Scotland has an active role in reviewing deaths from suicide and promoting any lessons learned across the NHS.

71. The Mental Welfare Commission for Scotland has statutory powers to carry out investigations or hold inquiries where there are concerns about the care or treatment of somebody with a mental illness, learning disability or related conditions.

72. The Care Inspectorate regulates social care, social work and child protection services. It is a legal requirement that the death of a person using a care service is reported to the Care Inspectorate.

73. Local authorities have systems in place to review some deaths, through a critical incident review or multi-agency review type process.

74. Stage 1 Report on Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Bill, 13th Report, 2015 (Session 4).

75. Section 37 of the Mental Health (Scotland) Act 2015.

76. Apparent Self Inflicted Death in Custody Audit Analysis and Review Report.

77. Included representatives from the Care Inspectorate, COPFS, the General Teaching Council, HSE, Mental Welfare Commission, Scottish Public Services Ombudsman and the Scottish Social Services Council.

78. Section 28 of the Act.

79. Section 3(1) of the Act.

80. COPFS written submission to Justice Committee, page 6.
http://www.parliament.scot/S4_JusticeCommittee/Inquiries/FA21._COPFS.pdf

81. http://www.gov.scot/Publications/2015/08/9101

82. Section 26(6) of the Act.

83. Sudden Deaths and Fatal Accident Inquiries 3 ^rd Edition, paragraphs 5-63 and 5-76.

84. Justice Committee, Stage 1 Report into the Fatal Accidents and Sudden Deaths etc. (Scotland) Bill, 13 ^th Report, 2015 (Session 4).

85. Section 1 of the Act.

86. Section 1 (4) of the Act.

87. May 2015.

88. S16: Further provision on the content and purpose of preliminary hearings is to be made by court rules.