FAI

Inquiry under the Fatal Accident & Sudden Deaths Inquiry (Sc) Act 1976 into the death of Thomas Bolesworth – Glasgow Sheriff Court, 23 January 2008

Wed, 30 Jan 2008 22:50:00 GMT

Following an FAI, Sheriff Mitchell determined that Thomas Bolesworth died on 6 January 2006 in Glasgow Royal Infirmary and that the accident which resulted in his death took place on 30 December 2005 in the meat preparation room of a butcher's premises in Duke Street, Glasgow. The circumstances of the accident were not fully established, but the Sheriff determined that, while working in the course of his employment as a butcher alone in the meat preparation room, Mr Bolesworth had removed the lid from the rose cooker in order to stir its contents. He had placed the lid on the mincer then lost his footing. He grabbed at the open cooker, causing it to topple over towards him and he fell onto the floor. The cooker fell onto his lower body and legs and some its contents – boiling meat plus some boiling water – spilt over him. He sustained approximately 38% mixed thickness scalding injuries to his face and body on his trunk, left arm and both legs. The cause of death was multi-organ failure, secondary to cardiogenic shock, secondary to myocardial infarction, secondary to sustaining those scalding injuries. The Sheriff held that there were no reasonable precautions by which the accident might have been avoided. The principal fact on which competing submissions were made related to why Mr Bolesworth had fallen. Although evidence had been led about the slip risk on the floor of the meat preparation area, the Sheriff did not find it established that Mr Bolesworth had slipped. There were no defects in any system of working which contributed to the accident. In his detailed note, the Sheriff made a number of observations. Although Mr Bolesworth had worked in the butcher's business for over 15 years, he had retired about a year before the accident. He had remained friendly with his former employer and had agreed to go back to work for a few days over the festive period. The Sheriff indicated, that while it was clear that neither gentlemen appreciated that this informal arrangement constituted a legal relationship, the legal representatives involved in the Inquiry had agreed that this was the case and that Mr Bolesworth had been working in the course of his employment when the accident occurred. Although he was only lending a hand on a temporary basis, all of the statutory duties incumbent on his employer applied to Mr Bolesworth. The Sheriff was critical of the decision of a representative of the Environmental Services Department of Glasgow City Council not to make any attempt to interview Mr Bolesworth in the 3 days following the accident when he was fit to be interviewed. The Sheriff described this as "a most serious error of judgement", particularly as there had been no other witnesses to the accident. In the Sheriff’s view, this error resulted in the local authority failing to discharge its statutory responsibility to investigate the accident. The Sheriff also indicated that the decision of the Procurator Fiscal’s Death Unit not to instruct a post mortem examination had turned out to be a most unfortunate one and had resulted in the Inquiry becoming more lengthy and expensive than it need otherwise have been. The Sheriff referred to a point raised by the solicitor acting on behalf of the family that no fair notice had been given of a line of inquiry which had been developed during the FAI. The family’s solicitor had made the point that "trial by ambush" was inappropriate at an FAI. It came to light during the Inquiry that Mr Bolesworth’s employer knew nothing about the legislation and regulations relating to health & safety at work. The Sheriff described this as "a wholly unacceptable and unsatisfactory situation". The Sheriff emphasised to all small businesses that it is the duty of every employer to ensure, so far as is reasonable practicable, the health, safety and welfare of all his employees. It is not sufficient only to rely on advice and guidance given by the Environmental Health Officers or other inspectors charged with health & safety at work responsibilities. It is the employer's responsibility to comply with all the requirements of health & safety at work legislation. The Sheriff also indicated that, in view of information which came to light at the Inquiry, Glasgow City Council needed to give further consideration to the instructions given to Environmental Health Officers regarding that they have to do when carrying out health & safety inspections in relevant premises, including butcher’s shops.

Determination in the Fatal Accident Inquiry into the death of Robert Cumming – Banff Sheriff Court, 29 November 2007

Wed, 05 Dec 2007 21:20:00 GMT

Fatal Accident Inquiry

Following a Fatal Accident Inquiry, Sheriff Johnston found that Robert George Cumming died at Hilton Farm, Boyndie on 9 March 2007. The cause of death was traumatic asphyxia as a result of being frequently butted on the chest and abdomen by a cow. Mr Cumming had been planning to tag a number of calves in the cattle shed at his farm. He was to be assisted by a student who was working at the farm during a college holiday. Mr Cumming had been aware that one of the cows was particularly protective towards her calf and that an attempt to separate her from the calf might lead to the cow becoming agitated and behaving aggressively. Mr Cumming had tried to isolate the calf from the cow, but the cow became agitated and started pushing and butting him aggressively. Mr Cumming had become pinned against the concrete buttress of the shed and had subsequently collapsed. The Sheriff concluded that there was nothing of a practical nature which could have been done to prevent the accident and that Mr Cumming had been well aware of the procedure and the risk associated with it. He described the accident as “very sad and tragic” and indicated that it merely highlighted the risks associated with tending live stock, risks which are often difficult to predict.

Inquiry under the Fatal Accidents & Sudden Deaths Inquiry (Scotland) Act 1976 in respect of the death of PC Kevin Lowe – Ayr Sheriff Court, 14th November 2007

Sun, 25 Nov 2007 12:20:00 GMT

Fatal Accident Inquiry - Death of Police Officer in Road Traffic Accident
Following a Fatal Accident Inquiry, Sheriff Millar determined that PC Kevin Lowe died at the junction of the A77 northbound and Symington North, Symington on 20 October 2006. The causes of death were: (1) (a) head and chest injuries due to (b) a road traffic accident. There were no reasonable precautions whereby the death and any accident resulting in the death might have been avoided and there were no defects in any system of working which contributed to the death or any accident resulting in the death. As the incident resulted in the death of a Police Constable on duty in an unmarked road traffic vehicle on the A77, the Sheriff thought it appropriate to consider any other facts which were relevant to the circumstances of the death in terms of Section 6(1)(e) of the 1976 Act. The Sheriff noted that there might be serious public concern about the use of unmarked Police vehicles and also about the locus of the accident. PC Lowe died responding to an emergency call when his vehicle collided with a vehicle being driven by a member of the public. He was an advanced Police driver and had worked in the Traffic Department for a number of years. He had been on his way to the scene of what the Police believed to be a serious hit and run accident. It was only after the event that it became apparent that the incident was less serious than had been thought. On the information available, the incident had been graded by Police Officers as grade 1, which called for immediate attendance and indicated an immediate threat to life. It was estimated that PC Lowe’s vehicle had been travelling at around 100mph as it approached the locus. The Sheriff dealt with the question of whether or not a response at the speeds achieved by PC Lowe in an unmarked Police vehicle was appropriate in the circumstances. Subject to a number of constraints, the Sheriff’s view was that the decision to drive the traffic car at high speed had been justified. There was a public perception locally that the junction at which the accident occurred was dangerous, although the accident records before the inquiry did not support that finding. There were, however, visibility problems for both drivers at the locus. The Sheriff concluded that PC Lowe’s death resulted from a combination of factors arising from unusual circumstances, which could not have been foreseen. In any Fatal Accident Inquiry the Court is not there to deal with hindsight. With hindsight it was always possible to find a better way to do things.

Inquiry under the Fatal Accident & Sudden Deaths Inquiry (Scotland) Act 1976 into the death of Margaret McCready McGinnis – Dundee Sheriff Court, May 2007

Thu, 08 Nov 2007 17:58:00 GMT

Fatal Accident Inquiry

Mrs McGinnis died at Ninewells Hospital in Dundee in July 2003. The cause of death was an arrhythmia brought on by chronic rheumatic heart disease. Following a Fatal Accident Inquiry, the Sheriff found that there were no reasonable precautions whereby the death might have been avoided and there were no defects in working which contributed to the death. Mrs McGinnis had had rheumatic fever as a child, and as a result, suffered from rheumatic heart disease in adulthood. This condition caused thickening and narrowing of the heart valves. In general, she had not been in good health. She had been an in-patient at Ninewells Hospital on 3 occasions in 2003. In the days leading up to her death, Mrs McGinnis had felt unwell. The day before her death, she had seen her GP, who had considered her heart rate dangerously low and thought that she should be admitted to hospital. On arrival at Ninewells Hospital, she had been seen by a senior doctor, Dr H. He had taken the view that Mrs McGinnis could be discharged, as he knew her well and was aware that she was due to return to the hospital 3 days later for a pre-arranged appointment. Mrs McGinnis had returned home and died the following day. At the Inquiry the family expressed a number of concerns about the deceased’s treatment. The Sheriff dealt in detail with each of those concerns but found that there was no evidence that these matters had contributed in any way to Mrs McGinnis’ death. The Sheriff accepted the view of a Consultant, who had given evidence at the Inquiry, that it was highly unlikely that a drug which Mrs McGinnis had taken for many years, Digoxin, had had any influence on her death. The Sheriff ruled the drug out as a material cause of death. He thought that the exercise of clinical judgement by Dr H in discharging the deceased was not unreasonable.

Inquiry Under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 into the circumstances of the death of Daniel Thomas Crew

Thu, 25 Oct 2007 12:37:00 GMT

Fatal Accident Inquiry - Death in Prison

A 21 year old, Daniel Crew, hung himself in Saughton Prison on 12 September 2006. He had been sentenced to 2 months’ imprisonment 8 days earlier for 2 offences of breach of the peace. Following a fatal accident inquiry, Sheriff Morrison, QC found that there were no reasonable precautions which could have prevented Daniel’s death and there were no defects in any system of working which contributed to his death. It had not been possible to ascertain why Daniel took his own life. On his admission to prison, Daniel had been assessed by a number of members of staff, including a prison doctor and a mental health nurse. He was not assessed as being at risk of attempting suicide. Before his admission to prison, Daniel had been seen by a number of mental health professions, none of whom appeared to identify a suicide risk.

Inquiry under the Fatal Accident & Inquiry (Scotland) Act 1976 into the circumstances of the death of Kyle Robert Brown - Edinburgh Sheriff Court 1/10/07

Thu, 18 Oct 2007 12:03:00 GMT

Fatal accident Enquiry

Kyle Brown, whose date of birth was 29 July 2004, died at the Royal Hospital for Sick Children in Edinburgh on 2 April 2006. The cause of his death was meningococcal septicaemia. Following a Fatal Accident Inquiry, Sheriff Lothian determined that Kyle’s death might have been avoided if call handlers at NHS 24 had been provided with a "routing tool" sufficient to enable them to initiate immediate emergency action in respect of the presentation of symptoms of meningococcal septicaemia. The absence of an appropriate routing tool constituted a defect in the system of working which contributed to Kyle’s death. Kyle’s mother had contacted NHS 24 and had spoken to a call handler. All calls to NHS 24 are received initially by a non-medically qualified call handler. Having taken a number of details, the call handler consults a routing tool, which is effectively a card with a number of symptoms written on it and an indication as to how those symptoms should be categorised. It appeared to the Sheriff that the routing tool in use at the time of Kyle’s death was not adequate to recognise the symptoms of meningococcal septicaemia. As a result, the call handler did not categorise Kyle’s condition as one requiring urgent attention. It was conceded on behalf of NHS 24 that the routing tool had been defective and it had been amended by the time of the Inquiry. When considering whether there were any reasonable precautions which might have prevented Kyle’s death, the Sheriff took the view that the use of the word "might" meant, effectively, that there was any chance of survival, no matter how slim. Having considered the medical evidence, the Sheriff decided that the possibility that earlier treatment might have saved Kyle’s life could not be ruled out as a possibility.

Determination in Fatal Accident Inquiry into the Death of Raymond James Birse

Mon, 17 Sep 2007 22:00:00 GMT

Fatal Accident Inquiry - Accident at Work

Mr Birse died on 10th May, 2006 . He had been working to remove the roof from a building when he fell. He suffered craniocerebral injuries as a result of blunt force trauma caused by the fall. Sheriff Veal confirmed that the Inquiry could not allocate responsibility for what happened. There had been an investigation by the Health and Safety Executive following Mr. Birse’s death. The Sheriff was supportive of, and would not fault, the HSE inspector’s decision not to take action against any party. He also saw merit in the HSE inspector’s observation that dismantling buildings and structures was a potentially dangerous activity which should only be carried out by contractors with the necessary expertise.

An Inquiry Under the Fatal Accidents and Inquiries (Scotland) Act 1976 Into the Sudden Death of Erik Funck Petersen

Thu, 23 Aug 2007 00:00:00 GMT

FAI - Section 6(1)(a) of the Fatal Accident and Su

FAI into the death of Neil William Cadger

Thu, 26 Jul 2007 00:00:00 GMT

FAI –

FAI into the death of Robert Shearer Campbell

Thu, 26 Jul 2007 00:00:00 GMT

FAI –

Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 Inquiry into the circumstances of the death of Gary Ackland

Tue, 10 Apr 2007 23:00:00 GMT

FAI

Inquiry Under the Fatal Accidents and Inquiries (Scotland) Act 1976 into the Sudden Death of Barry John Tierney

Mon, 05 Feb 2007 00:00:00 GMT

FAI

Inquiry under Fatal Accidents and Inquiry (Scotland) Act 1976 into the sudden death of Martin Gordon Blackley

Fri, 19 Jan 2007 00:00:00 GMT

Fatal Accident Inquiry

Inquiry under the Fatal Accident and Inquiries (Scotland) Act 1976 into the sudden death of James Hutchison

Thu, 07 Dec 2006 00:00:00 GMT

FAI

Inquiry under the Fatal Accident and Inquiries (Scotland) Act 1976 into the sudden death of Ian James Mackenzie

Tue, 14 Nov 2006 00:00:00 GMT

FAI

Inquiry Under the Fatal Accidents and Inquiries (Scotland)Act 1976 into the Sudden Death of Adrian John Fleurs

Fri, 27 Oct 2006 00:00:00 GMT

FAI - Death in Lawful Custody

Inquiry under the Fatal Accidents and Sudden Deaths Inquiry Act into the Sudden Death of Duncan Rowan MacLarty

Thu, 12 Oct 2006 00:00:00 GMT

FAI

Inquiry under the Fatal Accidents and Sudden Deaths Inquiry Act into the Sudden Death of Duncan Rowan MacLarty

Thu, 12 Oct 2006 00:00:00 GMT

FAI

Inquiry under the Fatal Accident and Inquiry Act into the Sudden Death of Jordan McLaughlin

Tue, 19 Sep 2006 23:00:00 GMT

FAI

Inquiry Under Fatal Accidents and Inquiry (SCOTLAND) Act 1976 into the Sudden Death of Derek Ian Crook

Wed, 26 Apr 2006 00:00:00 GMT

FAI death in custody

Inquiry into the Death of Daniel Christian Barclay

Thu, 20 Apr 2006 00:00:00 GMT

FAI in terms of Section 6(1) of the Fatal Accident

Inquiry into the Death of Mrs Margaret Graham

Wed, 19 Apr 2006 00:00:00 GMT

FAI in terms of Section 6(1) of the Fatal Accident

Inquiry Under the Fatal Accidents and Sudden Deaths Inquiry Act 1976 into the Sudden Death of Allan Menzies

Tue, 14 Mar 2006 00:00:00 GMT

Civil Proof - Breach of Building Contract:Death in

Inquiry under the Fatal and Sudden Deaths Inquiry Act 1976 into the Sudden Death of Mrs Janet Allen

Thu, 02 Mar 2006 00:00:00 GMT

The Fatal Accident Inquiry was held under Section

Inquiry Under the Fatal Accident and Sudden Deaths Inquiry Scotland Act 1976 into the Sudden Death of Robert Watson

Tue, 21 Feb 2006 00:00:00 GMT

Fatal Accidents and Sudden Deaths Inquiry (Scotlan

Inquiry into the Fatal Accidents and Inquiry (Scotland) Act 1976 into the Sudden Death of Carmella Kerr

Thu, 26 Jan 2006 00:00:00 GMT

FAI re death in hospital

Inquiry under the Fatal Accidents and Sudden Deaths Inquiry Act 1976 Into the Death of Moira Pullar

Thu, 08 Dec 2005 00:00:00 GMT

FAI