Fatal Accident Inquiries: review

Key Findings

17. While the number of deaths reported to COPFS has reduced in the last three years, there has been a significant increase in the proportion of deaths requiring investigation. This reflects:

• An evolution in the public's attitude to death, with a greater expectation of being involved in all important decisions regarding relatives and, in obtaining more information on the circumstances of the death;
• The increasing complexity of such investigations with advances in medical science and more sophisticated means of detecting the cause of accidents; and
• A changing landscape with an increasing number of regulatory and scrutiny bodies that have a duty to investigate a wide spectrum of different types of deaths.

18. Against this background, the number of FAIs held is extremely low, representing 0.7% of all deaths investigated. ^[12]

19. 70% of cases examined took more than 18 months from the date of death to the start of the FAI and 28% took more than three years.

20. Lengthy periods of unexplained delays prior to the start of an FAI adversely impacts on:

• The momentum of investigations and the operational capacity of investigating agencies - investigations characterised by lengthy intervals with intermittent requests for further inquiries to be undertaken run the risk of becoming fragmented and lacking continuity, particularly if the investigators have moved on to new investigations;
• The well-being of potential witnesses for whom the prospect of the inquiry "hanging over them" is a source of anxiety and concern;
• The confidence of the nearest relatives and the public; and
• The quality of the evidence and, in some cases, the purpose of the FAI.

21. Deaths investigations, conducted in local procurator fiscal offices and during the transition to centralise the investigation of deaths, were characterised by lengthy periods of inactivity and protracted and often unfocused investigations, resulting in unexplained delays in a significant number of cases.

22. The introduction of SFIU, a national specialist unit responsible for investigating all sudden, suspicious and unexplained deaths, has significantly improved the service provided by COPFS with a 64% reduction in the time taken between the date of death to the start of the FAI.

23. Whilst we found staff in SFIU were helpful and committed to providing a high quality service, and that there was improved management of deaths investigations and FAIs, there is scope to progress mandatory FAIs more expeditiously. Further, the systems for monitoring and recording FAIs are inconsistent and varied.

24. The impact of a sudden death of a loved one, especially if the death was caused by a criminal act, is devastating and the distress is compounded by the trauma of having to deal with an unfamiliar criminal justice system. The lack of a single point of contact during the criminal investigation and the FAI is a source of frustration and anxiety for nearest relatives. For an organisation that aspires to deliver a world leading public prosecution and deaths investigation service, the bereaved relatives' needs must be at the heart of the process; this requires a dedicated single point of contact throughout all proceedings.

25. A lack of understanding of the purpose and scope of an FAI contributes to the nearest relatives entering into FAI proceedings and/or raising issues at an advanced stage of the investigation, leading in some cases to the FAI being adjourned and additional parties becoming participants.

26. Witnesses and participants from recent FAIs report that they found the inquiry to be adversarial and, whether intended or not, it was seen as apportioning blame. One witness, who has given expert evidence in criminal proceedings and at FAIs, described giving evidence at an FAI as "like giving evidence at a criminal trial without the safety net".

27. Whilst there are cases where COPFS is reliant on investigators from external reporting agencies, such as the Health and Safety Executive, and where COPFS has no control over the investigation and timescale for the submission of reports, such cases represent a low proportion of death reports submitted to COPFS.

28. Fatal Accident Inquiries have played a crucial role in exposing failings and defects in working practices and systems, identifying precautions to avoid deaths occurring in similar circumstances and providing oversight on the way authorities have dealt with the deceased while in legal custody. The re-iteration of the purpose of Fatal Accident Inquiries in the Act, supported and underpinned by court rules designed to reinforce that purpose by focussing on the agreement of non‑contentious facts and encouraging proactive management of preliminary hearings, including early clarification of the issues that require to be examined, should assist in re-emphasising the public interest ethos of Fatal Accident Inquiries. To ensure Fatal Accident Inquiries continue to fulfil the important function that they have served requires all those involved, including COPFS, representatives of all participants and the judiciary to foster an environment that encourages transparency and frankness.