Fatal Accident Inquiries: follow up review

Overview

186. The thematic report was published in August 2016. We made 12 recommendations.

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

Status: In progress

Recommendation 2: SFIU should implement monthly reconciliations of all active deaths investigations between SFIU National and the SFIU Divisions.

Status: Achieved

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

Status: In progress

Recommendation 4: COPFS should introduce an internal target for progressing mandatory FAIs.

Status: Achieved

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.

Status: In progress

Recommendation 6: COPFS should ensure that all operational case related emails are recorded and imported into the case directory.

Status: In progress

Recommendation 7: 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.

Status: Achieved

Recommendation 8: 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.

Status: Superseded by the FAI Rules

Recommendation 9: COPFS should provide a single point of contact for the nearest relatives in all FAIs.

Status: Achieved

Recommendation 10: There should be a single point of contact for the nearest relatives throughout the criminal proceedings and any subsequent FAI.

Status: Achieved

Recommendation 11: SFIU should provide written notification to all participants on the issues COPFS intends to raise at the inquiry.

Status: Superseded by the FAI Rules

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.

Status: Not achieved

187. Given it is almost three years since the thematic report was published, the lack of progress in many areas is disappointing.

188. While COPFS continues to meet the published targets for deaths requiring investigation and routine deaths, there has been little progress in shortening the time line for mandatory FAIs with the first notice lodged within 12 months in only 37% of cases in our case review.

189. While the number of outstanding FAIs over 12 months is decreasing there are still 20 over three years old.

190. Undoubtedly resourcing has been an issue for SFIU and it is not yet at full complement following the additional resource that was secured in 2018. We are aware that efforts are ongoing to accelerate back filling vacancies and increasing the SFIU complement.

191. On a positive note the aims/objectives of the modernisation project should improve the effectiveness of the processes and procedures and ring-fencing a dedicated resource to tackle the backlog of older FAIs should address some of the concerns highlighted in this report.

192. We have made three new recommendations.

New Recommendations

• 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.
• In order to assess compliance with the Family Liaison Charter a record of the wishes of the family should be recorded on the charter template.
• SFIU should prioritise the FAI of any death of a young person in legal custody.

193. Given the number of recommendations that remain in progress, continuing delays in dealing with mandatory FAIs, the proposed completion of the modernisation project by the end of 2019 and the three new recommendations, it is appropriate for the Inspectorate to re-visit the investigation of FAIs in a further follow-up report next year.