Fatal Accident Inquiries: follow up review

The Inspectorate of Prosecution in Scotland's follow up review of their Fatal Accident Inquiries thematic which was published in August 2016.


1. Section 1(3)(a) and (b) of the Inquiries into Fatal Accidents and Sudden Deaths etc. (Scotland) Act 2016 (the 2016 Act).

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

3. Section 1(4) of the 2016 Act.

4. Section 26 of the 2016 Act.

5. Section 26(1)(b) of the 2016 Act.

6. Section 26(6) of the 2016 Act.

7. Section 28(1) and (2) of the 2016 Act. If a recommendation is addressed to someone who was not a participant in the inquiry they may similarly respond.

8. Section 28(5) of the 2016 Act.

9. Received Royal Assent on 14/01/2016.

10. Section 36 of the 2016 Act.

11. Section 2 of the 2016 Act.

12. Certain offshore deaths and accidents are treated as having occurred within Scotland – s.5 of the 2016 Act.

13. Section 2(3) of the 2016 Act

14. Sections 2(5) Includes being imprisoned or detained in penal institution; being in police custody; being held in custody on court premises or detained in premises used by armed services as service custody premises.

15. Section 2(4)(a) and (b) of the 2016 Act.

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

17. Section 4 of the 2016 Act.

18. The recommendations are discussed in a different order.

19. Located in Dundee, Aberdeen and Inverness.

20. Located in Edinburgh.

21. Located in Glasgow.

22. Established within SFIU in December 2015.

23. From March 2015 GPs submit reports electronically.

24. See Chart 4 below.

25. Source: COPFS MI Book.

26. Source: COPFS MI Book.

27. Source: COPFS MI Book.

28. Source: COPFS MI Book. A new electronic system for doctors to report deaths was introduced in 2015. In some cases, further inquiries are instructed and a new report is provided by the police with a new reference number being generated. The electronic report from the GP is closed with a duplicate marking. To avoid counting these deaths twice we deducted any reports closed with a duplicate marking from the total deaths reported from 2015/16 onwards.

29. Source: COPFS MI Book 15/04/19.

30. Source: COPFS MI Book 15/04/19.

31. Some FAIs may involve multiple deaths.

32. Source: IPS FAI Thematic Report 2016 and the SFIU FAI spreadsheet as at 02/04/19 (based on 'Date of FAI').

33. Source: SFIU spreadsheet as at 02/04/19 based on 'Date of FAI'.

34. Source: SFIU spreadsheet as at 02/04/19 based on 'Date of FAI'.

35. Source: SFIU as at spreadsheet 02/04/19 based on 'Date of FAI'.

36. Naming documents in a structured manner.

37. Source: SFIU spreadsheet as at 02/04/19 based on 'Deaths Closed' (119 mandatory and 12 discretionary cases).

38. Prior to the 2016 Act, it was known as an application for an FAI.

39. 56 cases.

40. 47 cases – nine cases were assessed as having a substantial criminal investigation. Of these five were progressed by HSD.

41. 14 cases – three were excluded as they were progressed entirely by HSD.

42. 30 cases – three cases were excluded as they had a substantive criminal investigation.

43. 4 cases (three discretionary FAIs relate to the same incident).

44. 7 cases – includes 5 cases where there was a substantive criminal investigation and two work-related cases.

45. 18 cases.

46. In seven cases where there was no record of the first notice, the date of when the advert was placed or intimation of the FAI was made to the nearest relatives was used.

47. Section 8 of 2016 Act.

48. Source: MI Book as at 30/04/19.

49. As categorised by SFIU.

50. Source: MI Book as at 30/04/2019.

51. Eight deaths relate to one incident.

52. As at 12/06/19.

53. As at 04/07/19.

54. Section 3(1) of the 2016 Act.

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

56. Act of Sederunt (Fatal Accident Inquiries Rules) 2017, Part 4 Expert Witnesses.

57. Rule 3.1.

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

59. 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.

60. 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.

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

62. HMIPS, Report on an expert review of the provision of mental health services, for young people entering and in custody at HMP YOI Polmont, May 2019.

63. The 10 most commonly measured Adverse Childhood Experiences (ACEs); Abuse – physical, verbal and sexual, Household Adversities – mental illness, incarcerated relative, domestic violence,parental separation, substance abuse, Neglect – physical and emotional.

64. IPS, Thematic report on the prosecution of young people in the Sheriff and Justice of Peace courts, 27 November 2018.

65. As at 19/07/19.

66. As at 19/07/19.

67. Determination of William Hume.


Email: carolyn.sharp@gov.scot

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