FAI

Fatal Accident Inquiry into the death of Kirsty Rutherford Thompson [2011] FAI 35

Wed, 21 Sep 2011 21:26:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Kirsty Rutherford Thompson (born 18th June 1987) died on 17th March 2001, aged 13, having been taken by ambulance to the Victoria Infirmary, Glasgow and pronounced dead at 6.56 am. In terms of section 6(1)(b), the cause of death was (a) peritonitis, due to a (b) perforated diverticulum, due to a (c) intestinal obstruction, due to an (d) internal hernia. In terms of section 6(1)(c) the reasonable precaution that might have prevented the death was for a doctor to take into account current physical observations readily available relating to the patient before deciding upon her discharge from hospital. Several relevant facts were set out in terms of section 6(1)(e).

The deceased became unwell on 8th March 2001, suffering from abdominal pain and vomiting. On 9th March, her GP diagnosed her with a viral gastro-intestinal infection. She was then taken to Glasgow Emergency Medical Services, where she was diagnosed with haematemesis and transferred to the Victoria Infirmary. She was ultimately diagnosed with oesophagitis and on 14th March she was discharged from hospital with medication. On returning home, she continued to feel unwell and on 16th March, she was examined by a doctor at home. She then collapsed at around 5.45am on 17th March. Her father tried to revive her with mouth-to-mouth resuscitation and heart massage and an ambulance was called. However, her pulse had stopped by the time paramedics arrived and she was pronounced dead at 6.56am at the Victoria Infirmary.

Having heard evidence, the Sheriff noted that no criticism could be levelled at the standard of care Kirsty received while in hospital, nor of her medical examination at home. It was also noted that she had a very rare congenital condition which caused the bowel to herniate and become obstructed.

The Sheriff found that Kirsty had been discharged from hospital prematurely and that delaying her discharge may have led to surgical intervention, which would have saved her life. There were a number of indicators during her period in hospital that, if taken into account, may have led to the diagnosis of her underlying condition and should have prevented her discharge from hospital. However, the Sheriff declined to find that there was a systemic failure in terms of section 6(1)(d).

FAI into the Deaths of Ramilito Capangpangan, Benjamin Rosillo Potot and Rimants Venckus, Sheriff Marysia Lewis, Peterhead Sheriff Court, 23rd August 2011

Thu, 15 Sep 2011 21:16:21 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 the sheriff found that Ramilito Capangpangan (DOB 12.12.74) and Benjamin Rosillo Potot (DOB 24.05.75) died within the galley and Rimants Venckus (10.02.58) died within the wheelhouse on board the vessel “the Vision ll" berthed at Provost Park Jetty, Balaclava Inner Harbour, Fraserburgh. The deaths occurred between 00.30 and 01.30am on Friday 1st August 2008. In terms of s.6(1)(b) the deaths were caused by the inhalation of smoke and fire gases. Formal determinations were made under s.6(1)(c) and (e).

Background
The accident resulting in the deaths was caused by an electric fan heater fitted within a seating unit in the galley of the Vision ll. The air supply to the fan heater was either slowed or stopped by items within the storage area blocking the air vents in the back of the fan heater. This caused the fan heater to overheat and ignite.

Determination
In terms of s.6(1)(c) the reasonable precautions by which the accident and the deaths might have been avoided are as follows: the fan heater should have been housed within a plywood box; combustible items should not have been stored next to the fan heater; the galley fire door should have been kept closed at all times; crew members should have been provided with adequate training and undertaken regular emergency drills; emergency exits should have been regularly inspected and maintained; fire detection system should have been incapable of being turned off and should have been connected to a secondary power source; and additional fire alarms should have been fitted.

In terms of s. 6(1)(e) two facts were identified as relevant to the circumstances of the deaths. First, there was confusion as to what organisation should approve the installation of fan heaters and tie backs on galley doors. As a result these items were not inspected. Second, if a scaffold pole had not been used to shut the watertight door onto the main deck the crew might have had another escape route.

FAI into the Death of John Aitken, Sheriff Ross, Dumfries Sheriff Court, 16 August 2011

Thu, 15 Sep 2011 21:13:05 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that John Aitken died within ward 14 at Dumfries and Galloway Royal Infirmary (DGRI), Dumfries on 1 April 2009 at 18.00 hours. In terms of s.6(1)(b), the cause of death was (a) Cardiorespiratory arrest (b) Hypoxic brain damage and (c) Widespread severe bronchopneumonia. Formal determinations were made under s.6(1)(c) and (d).

Background
The deceased had experienced problems with his oesophagus since 1997. In July 2008 a tumour was discovered. An endoscopic examination was carried out which resulted in an oesophageal perforation, a common complication of the procedure. Mr Aiken underwent further surgery a few days later. He developed a complication whereby his lower limbs became paralysed. He was transferred to the Acute Rehabilitation Ward (ward 14) in August 2008. By March 2009 his condition had worsened and a decision was taken to transfer him to the Intensive Care Unit (ICU).

An ICU doctor had instructed that Mr Aitken’s blood saturation levels be continuously monitored before and during the transfer. Nursing staff did not record this instruction on medical notes. They were unable to find a blood monitoring machine so carried out the transfer without one. Mr Aiken was provided with an oxygen mask and cylinder during the transfer. It is unclear whether the oxygen supply was switched on. Staff moved Mr Aitken from the ward towards the lift. They then noticed that he did not look well and rushed him back to ward 14. When doctors arrived Mr Aitken had no pulse and was not breathing. Resuscitation was not performed in light of a previous “Do Not Resuscitate” instruction.

Determination
In terms of s.6(1)(c) there were a number of reasonable precautions which could have been been taken to avoid the death. Medical instructions regarding blood saturation levels should have been recorded in nursing notes. The levels should have been closely monitored before and during the transfer to ICU. Mr Aitken’s ICU doctor should have been informed that there was no machine available to monitor levels during the transfer.

In terms of s.6(1)(d) there were a number of defects in the system of working which contributed to the death. At the time of the death there was no formal policy for the care of patients during ward transfers. Blood levels and other information was not recorded on Mr. Aitken’s chart prior to transfer. Blood levels were not monitored during the transfer and Mr Aitken did not receive oxygen during the transfer. Staff lacked adequate training in the requirements for the transfer of ill patients.

FAI into the Deaths of Joanne Isabel Mackie or Winsborough and William Anderson, Sheriff McSherry, Dunfermline Sheriff Court, 8th August 2011

Thu, 15 Sep 2011 21:10:11 GMT

Mrs Winsborough

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Joanne Isabel Mackie or Winsborough (DOB 07.05.75) died at her home at 29 Elmwood Terrace, Kelty, Fife between the hours of 6.30and and 11am on the 17th April 2009. In terms of s.6(1)(b), the cause of death was suppurating pneumonia. No formal determinations were made.

Mrs Winsborough was a healthy woman aged 33. She started feeling unwell with nausea and diarrhoea around the 10th April 2009. Her symptoms worsened and she saw her GP on the 14th April. She was diagnosed with gastroenteritis. She wanted a second opinion so attended A&E. The doctor there confirmed her GP’s findings and advised that she continue to take fluids to keep dehydration under control. By the 16th April she was significantly dehydrated. On 17th April Mr Winsborough went to work with the intention of taking his wife to hospital when he came home. At 10.30am his daughter called him to say that Mrs Winsborough was not breathing and her lips were blue. Paramedics attended the house but could not resuscitate her.

Mr Anderson

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that William Anderson (DOB 01.09.56) died at Queen Margaret Hospital, Dunfermline, Fife at 5.53pm on 9th September 2009. In terms of s.6(1)(b), the cause of death was a) pneumonia and b) H1N1 influenza (swine flu). No formal determinations were made.

Mr Anderson was a healthy man aged 53. He developed flu-like symptoms on 31st August 2009 which worsened over the next few days. He called the NHS24 swine flu helpline on 5th September and was advised to go to A&E. He was diagnosed as suffering from probable swine flu and possible lower respiratory tract infection. It appears that Mr Anderson was not aware of the H1N1 diagnosis as he told his son-in-law that he was relieved to have been diagnosed with ordinary flu. His condition worsened on 6th and 7th September. He refused to see his GP on the basis that he wished to give the antibiotics time to take effect. At 1.45am on 8th September Mr Anderson suddenly sat up in bed and told Mrs Anderson that he thought he had had a stroke. As he was getting dressed he collapsed and never regained consciousness. He was taken to hospital and died the following day at 5.53pm.

FAI into the Death of Daryl Malcolm Shearer, Sheriff Principal Young, Dingwall Sheriff Court, 14th July 2011

Thu, 18 Aug 2011 17:04:38 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 the sheriff found that Daryl Malcolm Shearer (DOB 07.05.89) died while in custody at Dingwall Police Station, Strathpeffer Road, Dingwall, Ross-shire at about 8.15am on 27th October 2008. In terms of s.6(1)(b) the cause of death was the cumulative effects of head and neck trauma and intoxication with dihydrocodeine and diazepam. A formal determination was made under s.6(1)(c).

Determination
Under s.6(1)(c) there were two reasonable precautions whereby Mr Shearer's death might have been avoided. He could have refrained from becoming involved in fights with other young men and he could have refrained from abusing controlled drugs.

Although no other determinations were made, the sheriff noted a number of points arising from the case that the police may wish to consider. Firstly, procedures for following medical instructions for custodial prisoners should be improved. Secondly, changes could be made to allow custodial officers to replay recordings of prisoners’ activities while in their cells. Finally, procedures for ensuring prisoners actually take prescribed medication could be improved.

Fatal Accident Inquiry into the death of Kenneth McLean [2011] FAI 26

Wed, 06 Jul 2011 01:35:42 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Kenneth McLean (aged 53) died on 13 October 2005 at 09:48 hours at the Western Infirmary, Glasgow. In terms of section 6(1)(b), the cause of death was neck and chest injuries due to a fall from a height of around nine metres from a general access scaffold. The cause of the fall was the installation, to the exterior face of the scaffold, of a hop up containing two metal battens without a tie bar.

The deceased was, at the time of death, working as a roughcaster with Talepine Limited, trading as Quickseal Specialist Contractors, who were subcontractors in respect of external render works at a housing development in Partick, Glasgow. The principal contractor, PBL Limited, erected a hired six-level general access scaffold at the site. Two wheelbarrows had been taken to the fifth level via a hoist. Mr McLean removed one wheelbarrow. While trying to remove the second, he placed his weight on the insecure exterior hop up board with the missing tie bar. The board moved and caused him to fall to the ground with the board itself.

Having heard evidence from several witnesses, the Sheriff concluded that the accident was entirely avoidable. In terms of section 6(1)(c), the reasonable precaution whereby Mr McLean’s death might have been avoided would have been for PBL to eliminate the gap between the hoist and scaffold by extending the scaffold platform or using a different hoist. The Sheriff noted counsel for the deceased’s family’s invitation to find that a reasonable precaution would have been the insertion of a tie bar in the hop up platform at level five, bay five. However, while that was technically correct, the Sheriff declined to make that finding as it could imply legitimacy in use of such platforms to the exterior face of the scaffold, contrary to the scaffold user instructions.

Several failures in respect of the management and maintenance of the site were highlighted and defects in the system of working which contributed to the death were set out in terms of section 6(1)(d). These related to failures by PBL to employ suitably qualified scaffolders; to appoint a Site Manager to arrange weekly scaffold inspections; to ensure only authorised scaffolders erected or altered scaffold; to access risk assessments from sub-contractors; to induct sub-contractors’ employees; and to ensure the fifth level platform was not used to access the hoist. Talepine also failed to draft an appropriate risk assessment; to check the scaffold was property erected; to check appropriate arrangements were made for scaffold alteration; and to check that Mr McLean had been inducted at the site.

No findings were made in respect of section 6(1)(e).

Fatal Accident Inquiry into the Deaths of Brian French and Colin William Ferguson, Sheriff Norman McFadyen, Ayr Sheriff Court, 24th June 2011

Fri, 01 Jul 2011 13:28:56 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 the sheriff found that Brian French (DOB 21.06.68) and Colin William Ferguson (DOB 27.11.69) died at the Pennyvenie Opencast Coal Mine Site near Dalmellington on 26 February 2007 at around 1pm. In terms of s.6(1)(b) Brian French’s death was caused by multiple injuries. Colin William Ferguson’s death was caused by asphyxia due to a crush injury to the chest. Both deaths were caused by an accident at work. Formal determinations were made under s.6(1)(c), (d) and (e).

Background
At the time of the accident the deceased were working in the course of their employment with Castlebridge Plant Limited. The accident occurred when another worker, Alan Shannon, turned his dump truck into a stationary Land Rover occupied by Brian French and Colin Ferguson, killing them both. The Land Rover was parked in the dump truck’s blind spot.

Determination
In terms of section 6(1)(c) the sheriff identified a number of reasonable precautions whereby the deaths might have been avoided. Radios could have been made available and the deceased could have used them to alert others to their presence. Alan Shannon could have been more alert and reversed or stopped when the collision occurred. Scottish coal could have improved their procedures concerning the driving of light vehicles and dump trucks. Buggy whips could have been installed on light vehicles and cameras on trucks to improve their visibility. A system of segregation between large and small vehicles could have been implemented.

In terms of s.6(1)(d) there were several defects in systems of work which contributed to the deaths. These concerned: communications systems (particularly radio availability); visibility aids for vehicles; segregation of large and small vehicles; traffic management; operational procedures for small vehicles and trucks; and training of drivers.

In terms of Section 6(1)(e) of the 1976 Act there were a number of other factors which were relevant to the circumstances of the deaths. Drivers should have been made aware of the consequences of reading newspapers in their cabs. Better training should be provided by Scottish Coal across the industry. Health and Safety Inspectors should press home the dangers of working with large machinery and make enquiry about radio usage and traffic management as part of their inspections. Consideration should be given to updating the Quarries Regulations Approved Code of Practice. The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 should be amended to cover dangerous occurrences where there is a high risk of serious injury or fatality.

Fatal Accident Inquiry into the Deaths at Rosepark Nursing Home, Sheriff Principal Brian Lockhart, 19th April 2011

Thu, 30 Jun 2011 18:27:25 GMT

This was a fatal accident inquiry into the deaths of 14 residents of Rosepark Care Home; Annie Stirrat, Julia McRoberts, Robina Worthington Burns, Isabella MacLeod, Margaret Lappin, Mary McKenner, Ellen Veronica Milne, Helen Crawford, Annie Florence Thomson, Margaret Dorothy McWee, Thomas Thompson Cook, Agnes Dennison, Margaret McMeekin Gow and Isabella Rowlands MacLachlan. The sheriff found that all 14 residents died as a result of a fire at the care home on 31st January 2004.

In terms of s.6(1)(c) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 the sheriff found that a number of reasonable precautions could have been taken to avoid the deaths. These were:
1. The loose cable that caused the fire could have been better protected.
2. Electrical installations could have been regularly inspected and tested.
3. The cupboard where the fire started could have been kept securely closed.
4. Bedroom doors could have been fitted with smoke seals and automatic close mechanisms.
5. Combustible material could have been stored away from the cupboard’s electrical installations.
6. The corridor in which the cupboard was situated could have been subdivided to reduce the number of residents to be evacuated.
7. Fire dampers could have been installed.
8. The fire alarm panel could have been better designed to provide clearer information.
9. Better training could have been given to staff.
10. Staff could have phoned the fire brigade as soon as the alarm sounded.
11. Staff could have undertaken adequate risk assessment.
12. Fire Brigade staff could have made earlier calls for more resources had they been made fully aware of the situation.

In terms of s.6(1)(d) a number of defects in systems of work were identified as causing or contributing to the deaths. The following systems were inadequate:
1. Maintenance of electrical installations.
2. Staff training in fire procedure.
3. Management of fire safety.
4. Management of the Rosepark’s construction process.
5. Regulation of nursing homes by Lanarkshire Health Board.

In terms of s.6(1)(e) a number of facts were identified as relevant to the circumstances of the deaths. These were:
1. Fire precautions legislation requiring fire brigades to inspect care homes was not complied with. The legislation only required the Care Commission to inspect fire safety records and not equipment. The two bodies were not clear about their respective roles with respect to fire safety.
2. A completion certificate was awarded to Rosepark when it had failed to comply with building regulations in respect of the installation of fire dampers.
3. There was no external check to ensure that ventilation and electrical installations had been inspected and tested.
4. There was no statutory requirement for persons assessing fire risk to be suitably qualified.

Since the fire a number of significant developments have served to improve fire safety in care homes. The fire brigade carried out advisory visits to all care homes to eliminate fire safety risks and overhauled its procedures for dealing with fires in nursing homes. The Care Commission appointed a Fire Safety Advisor to ensure that the two bodies work more closely on fire safety. Memoranda of understanding were drawn up between them. The regulatory framework in relation to fire safety was strengthened by the Fire Safety (Scotland) Regulations 2004. Finally, building standards regulations were also reviewed to address fire safety concerns.

Fatal Accident Inquiry into the Death of Philip Holmes Saffrey, Edinburgh Sheriff Court, 24th May 2011

Wed, 29 Jun 2011 22:47:18 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Philip Holmes Saffrey (DOB 17.03.67) died at approximately 1.30 am on 15th July 2010 en route from Saughton Prison to Edinburgh Royal Infirmary. In terms of s.6(1)(b), the cause of death was cocaine toxicity. No other formal determinations were made.

Background

Philip Saffrey had been using cocaine for many years and was well experienced in the supply, transportation and importation of cocaine. On 10th July 2010 he was arrested (along with two co-accused, Luis Hidalgo and David Carpenter) and charged with the supply of high-value cocaine. The deceased and Luis Hidalgo were remanded in custody and on the evening of 14th July 2010 were sharing a cell at Saughton Prison. Despite having been comprehensively searched by various custody officers, the deceased had managed to smuggle cocaine into the cell. He ingested a fatal quantity of cocaine and, before becoming unresponsive, wrote a note indicating that he was committing suicide. The note also cleared his two co-accused of any wrongdoing. Luis Hidalgo alerted the prison authorities and an ambulance was called. However, Mr Saffrey did not regain consciousness. He was transferred to Edinburgh Royal Infirmary where he was declared dead shortly before 3 am.

Determination

The sheriff made no formal recommendations in this case. He was satisfied that the prison and custody staff acted appropriately and carried out adequate searches despite the fact that drugs were not discovered. The sheriff ruled out the likelihood of Mr Saffrey ingesting the cocaine involuntarily. On the balance of probabilities it was more likely that he committed suicide.

Fatal Accident Inquiry into the Death of James Alexander Fraser, Sheriff Graeme Napier, Kirkwall Sheriff Court, 10th June 2011

Tue, 21 Jun 2011 16:27:36 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that James Alexander Fraser (DOB 20.08.64) died at Gorn Farm, Rendall, Orkney between 3.30 pm and 5 pm on 3rd January 2011. In terms of s.6(1)(b), the cause of death was traumatic asphyxia as a result of chest compression. Formal determinations were made under s.6(1)(c)(d) and(e).

Background
Mr Fraser was a self-employed farmer. On the day of his death he was carrying out maintenance work on a round baler. The baler was equipped with 2 separate safety devices to prevent the tailgate dropping down unintentionally. Firstly the baler’s tailgate was operated by two hydraulic ‘rams’ which were controlled by an isolation valve. Secondly, the baler had a hinged mechanical support known as a 'scotch' which acted as a physical barrier preventing the tailgate from lowering if the isolation valve failed.

While Mr Fraser was working under the tailgate the isolation valve disengaged and the tailgate lowered unexpectedly. As Mr Fraser had not used a scotch he became trapped in the lowered tailgate and was asphyxiated. Mr Fraser was discovered by his son Gavin at around 5pm. It was clear that Mr Fraser was already dead at that time.

Determination
Under s.6(1)(c) the sheriff found that the accident would not have occurred if Mr Fraser had used a scotch on the baler. Under s.6(1)(d) the sheriff identified that the main defect in the system of work was Mr Fraser’s failure to carry out a risk assessment for the planned maintenance operation. Had he done so he would have been able to take steps to avoid the accident. Under s.6(1)(e) the sheriff noted two facts that were relevant to the death. First, the deceased was working in cramped conditions which increased the potential for accidents. Second, the Health and Safety Executive have issued guidance that is relevant to the deceased’s area of work and these are available free of charge.

Fatal Accident Inquiry into the Death of Alexander John Moar, Sheriff Valerie Johnston, Kirkwall Sheriff Court, June 2011

Tue, 21 Jun 2011 16:22:27 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Alexander John Moar (DOB 26.11.83) died in Hoy Sound on 16th June 2007 between 12.30 am and 12.45 am. In terms of s.6(1)(b), the cause of death was drowning by sudden immersion in cold water. Formal determinations were made under s.6(1)(c) and (e).

Background
Late at night on the 15th June 2007 Alex Moar, an experienced sailor, embarked on a journey from Orkney mainland to the island of Hoy after mentioning to friends that he might attend a party on the island. He had been drinking with friends during the afternoon and evening but set off on his 17 ft Dory alone. He did not have a lifejacket, survival suit, spare engine or VHF radio on board. At around 12.30 am the Dory’s anchor rope mechanism suddenly failed and the boat capsized. Alex sent up a red distress flare which was spotted by an islander who made a 999 call. As the source of the flare could not be identified, the coastguard began investigating the source. After a land source was ruled out, the lifeboat was launched around 30 minutes after the flare sighting. The capsized Dory was discovered around one nautical mile from the lifeboat centre. The subsequent search for Alex was unsuccessful and his body was eventually discovered on the shoreline of Calf of Flotta on the 18th July 2007.

Determination
The sheriff found that, under s.6(1)(c), the deceased could have taken reasonable precautions to avoid his death such as: notifying the Coastguard of his voyage; wearing a lifejacket and survival suit; carrying a VHF radio; carrying adequate fuel; and installing an independent secondary engine.

Under s.6(1)(e) a number of facts were relevant to the circumstances of the death. In addition to the facts noted above, these were: that the Coastguard Acting Watch Manager responded in accordance with prescribed procedures and protocols; that by 12.40 am Coastguards on call had been instructed to make visual checks from the shoreline; that at the date of the incident the water temperature was between 10 and 11 degrees Celsius; and that there was an ebb tide running westerly at between 5 and 6 knots.

Fatal Accident Inquiry into the Death of David Clark, Sheriff Ian Dunbar, Dunfermline Sheriff Court, 29 May 2011

Tue, 21 Jun 2011 16:17:02 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that David Clark (DOB 18.06.86) died at 37 Grainger Street, Lochgelly, Fife at approximately 1.19 am on 12th May 2007. In terms of s.6(1)(b), the cause of death was the adverse effects of heroin and methadone. A formal determination was made under s.6(1)(c).

Background
David Clark was a heroin addict who, at the time of his death, smoked or injected around £40 worth of heroin per day. He was made subject to a Drug Treatment and Testing Order in April 2007 and placed on a Methadone programme. On the first day of his treatment, 10th May 2007, he was prescribed 80mgs of Methadone. The next day David was seen by the doctor and was given 100mgs of Methadone. Later that day he smoked and injected heroin with his flatmate Robert Palmer at their flat at 37 Grainger Street. In the evening David fell asleep on the sofa and was heard snoring. Later in the evening David’s brother Ryan noticed that he had vomited and was not breathing. Ryan called for an ambulance and attempted resuscitation. Paramedics arrived and continued resuscitation without success.

Determination
In terms of s.6(1)(c) the sheriff found that only reasonable precaution whereby the death might have been avoided was if David Clark had not taken heroin after he had been prescribed and taken methadone. In addition, the sheriff noted three issues that should be addressed to improve services. First, the sheriff suggested that the pathology/toxicology services available in Dundee should be upgraded. Second, guidelines and protocols for methadone treatment should be better defined and staff made fully aware of them. Finally, improvements should be made in note-taking and communication between staff.

Fatal Accident Inquiry into the death of Andrew Raeside [2011] FAI 16

Thu, 16 Jun 2011 18:22:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Andrew Raeside died at 00.20am on 3rd February 2010, within a Mercedes tractor unit cab, on its impact with the Loch Faskally foreshore after breaching bridge parapet barriers, detaching from the trailer unit and falling to the foreshore. The accident occurred on the Coronation Bridge on A9 trunk road, 460 metres south of its junction with B8019 road.

In terms of section 6(1)(b), the cause of death was multiple cardiothoracic injuries caused by blunt force trauma resulting from the deceleration force caused by the cab's impact with the ground. The cause of the accident was driver error. In terms of section 6(1)(c), the accident might have been avoided by driving within the speed limit applicable at the locus and at a speed appropriate for the road conditions at the time of the accident.

The deceased was, at the time of death, working as an HGV driver with Brogan Fuels and returning from Muir of Ord, where he had earlier made a delivery of kerosene. At the time of the accident, the weather and road conditions were not ideal, with snowfall resulting in a slippery road surface and reduced visibility.

Having heard evidence, the Sheriff noted that Mr Raeside was not wearing his seat belt, but this did not contribute to his death, nor was the absence of an airbag in the tractor cab significant. In respect of possible causes of the accident, it was clear that Mr Raeside lost control of his articulated lorry, which collided with the barrier bounding the northbound carriageway of the Coronation Bridge and the cab breached that barrier. Thereafter the cab disconnected from the trailer and fell, impacting with the ground below the bridge. The Sheriff was satisfied that the lorry jacknifed for the reasons set out in the Police crash investigation report. Road conditions were a possible contributory factor to the accident, and it was likely the deceased was travelling at a speed in excess of the applicable speed limit for the vehicle. Whilst he was satisfied that the deceased was travelling at excessive speed for the road and conditions, in light of the evidence, the Sheriff could not come to any determinative conclusion that that played any part in the accident, although it was a relevant factor to be considered in terms of section 6(1)(c). The Sheriff made a determination to that end. Further, in light of the conclusions reached by the accident investigators to the effect that all of the causes of the accident were to some extent attributable to driver error, the Sheriff considered that he could make that general determination.

The Sheriff did not consider that he could make any determination regarding the bridge design. Even if the bridge parapet had been designed to the higher standard, it was unlikely that it would have contained the tractor unit. In any event, the Sheriff did not consider any upgrade of the bridge parapet could be considered reasonable in the circumstances. No findings were made in respect of section 6(1)(d) or (e).

Fatal Accident Inquiry into the death of Liam Joseph Boyle [2011] FAI 17

Thu, 09 Jun 2011 22:13:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Liam Joseph Boyle (born 24 May 2007) died on 28th February 2010 at 12.12pm at the Southern General Hospital, Glasgow. In terms of section 6(1)(b), the cause of death was electrocution.

The deceased, aged 21 months at the date of death, was fatally electrocuted after picking up a plug attached to an un-terminated flex, left unattended at his home by workmen replacing an oven. It appeared that Liam had plugged the plug into a socket and was electrocuted upon touching the live bare wires on the flex. He was found lying on the floor by his brother, who assumed he was sleeping. His mother also thought he was sleeping, but then noticed a spot of blood on the floor near his mouth and saw the cable wire underneath him. The cable was plugged into an electrical wall socket and the switch was in the on position. Liam’s mother switched off the electric current and scooped up Liam, whose body felt lifeless. She administered mouth to mouth resuscitation and telephoned for an ambulance. Despite further efforts to resuscitate Liam, by both paramedics at the scene and in the ambulance and medical staff at the hospital, he was pronounced dead at 12.12pm.

Having heard evidence, the Sheriff set out his conclusions in respect of the circumstances surrounding Liam’s death. In terms of section 6(1)(c), the reasonable precautions whereby the death might have been avoided were that (1) the cable and plug be kept in a place where Liam could not reach them once they had been disconnected from the oven while it was being replaced; and (2) once that work had been completed, they be removed as part of the necessary task of clearing up the tools and equipment had been brought to the house to carry out the work. The Sheriff noted that the primary responsibility for satisfying these reasonable precautions must rest with the person undertaking the job. It was concluded, on the evidence, that no responsibility for keeping the cable and plug in a place where Liam could not reach them could attach to any of the others present in the house at the time. The Sheriff noted that a third reasonable precaution had been proposed by the Crown in respect of child-safe blanking plugs in the house, but was not satisfied that the evidence led was sufficient to conclude that that precaution should be included in his determination. No findings were made in terms of section 6(1)(d) or (e).

Fatal Accident Inquiry into the death of John Dunlop [2011] FAI 25

Thu, 09 Jun 2011 21:59:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that John Dunlop (born 4th October 1948) died on 16th May 2009 at the Royal Infirmary, Edinburgh. In terms of section 6(1)(b), the cause of death was (i) ischaemic and hypertensive heart disease; (ii) multiple sclerosis.

The deceased was aged 60 and a serving prisoner in custody at the time of death. He had been previously diagnosed with a neurological condition linked to multiple sclerosis. He had spent most of his prison sentence at HM Prison Peterhead, where his regular pain relief medication, tramadol, had recently been withdrawn on a neurologist’s advice. In March 2009, Mr Dunlop was transferred to HM Prison Saughton Edinburgh as part of a pre-release programme. On 27 April 2009, he visited the Saughton prison doctor, complaining about the side-effects of his new pain medication. The prison doctor prescribed tramadol again on a supervised basis.

On 16th May at around 7.30am, Mr Dunlop was found lying unconscious on his cell floor. A pulse was detected and cardio-pulmonary resuscitation was administered. An ambulance was called and he was taken to the A&E department at the Royal Infirmary, Edinburgh, where he was pronounced dead by hospital staff at 8.50am.

Having heard evidence, the Sheriff was satisfied that the level of tramadol found in Mr Dunlop’s blood at post-mortem had not contributed to his death. He was satisfied from the pathologist’s evidence that Mr Dunlop’s heart disease was such that he could have died at any time. He had been taking tramadol for many years and his body had built up a level of tolerance. It was appropriate, in the circumstances, for the prison medical authorities to prescribe tramadol to Mr Dunlop. It had been prescribed at an appropriate level and appropriately monitored by the prison medical staff.

The Sheriff was satisfied that there were no suspicious circumstances surrounding Mr Dunlop's sudden death. All of the circumstances pointed to Mr Dunlop tragically sustaining a heart attack, and he had been found quickly by prison staff and given immediate medical attention. The Sheriff was satisfied that a thorough investigation was carried out by the authorities at the time into the circumstances of the death and there were no other matters or recommendations to be included in his determination. Accordingly, no findings were made in terms of section 6(1)(c), (d) or (e).

FAI into the Death of William Charters Brown, Greenock Sheriff Court, 7th May 2010

Wed, 01 Jun 2011 17:58:41 GMT

In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that William Charters Brown died at The Coronary Care Unit of Inverclyde Royal Hospital, Greenock on 23rd November 2007 at 7.00am. In terms of s.6(1)(b), the cause of death was pulmonary thrombo-embolism, due to deep venous thrombosis of the right calf. No other formal determinations were made.

Background:
Mr Brown had undergone a heart transplant fourteen years prior to his death. He also suffered from arthritis and had previously been treated for a brain abscess and was prescribed numerous medications including steroids. Immediately prior to his death he was incarcerated in HMP Gateside Prison in Greenock, having been charged with homicide, during which incident he had also received a number of injuries including a stab wound to his right hip.

On 6 November 2007, whilst in the prison, he complained of chest pain radiating through to his back following which he was transferred to Inverclyde Royal Hospital. Over the next few days his condition appeared to stabilise and he was discharged back to prison on 14 November 2007. On 19 November he once again complained of shortness of breath and chest pain, and was transferred back to Inverclyde Royal Hospital. On the morning of 23 November he developed sudden onset severe chest pain before collapsing. Cardiopulmonary resuscitation was attempted but this was unsuccessful, and he was formally declared dead at 0700 hours. Mr. Borwn’s fatal pulmonary embolism was diagnosed post mortem.

Determination:
The sheriff found that there were no reasonable precautions which could have been taken to avoid the death. The pulmonary embolism could only have been discovered by an MRI scan; however, this would not necessarily have shown that there was a thrombosis that would cause death. The diagnosis made was acute coronary syndrome and not pulmonary embolism. This diagnosis was appropriate given the deceased’s symptoms.

Fatal Accident Enquiry into the Death of Nasrullah Khalid, Sheriff Kenneth Ross, Dumfries Sheriff Court, 9th March 2011

Mon, 16 May 2011 12:28:43 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Nasrullah Khalid died within cell B/17 at H M Prison, Terregles Street, Dumfries on 23 November 2009 between the hours of 3.15pm and 4.55pm. In terms of section 6(1)(b), the cause of death was (a) Ischaemic Heart Disease (b) Coronary Artery Thrombosis and (c) Coronary Artery atherosclorosis. A formal determination was made under section 6(1)(c).

Background:

Mr. Khalid had suffered from a heart condition since 1996 when he had had a heart attack. The symptoms of his condition were stable angina, hypertension and atherosclerosis. For the three years prior to his death the deceased exercised regularly in Dumfries Prison gym. There was no medical reason why Mr. Khalid should not have participated in the exercise regime.

At about 1.50pm on 23rd November 2009 Mr. Khalid attended the prison gym as usual. About five minutes before the end of his routine the deceased experienced nausea and pains in the centre of his chest. He was examined by the duty nurse who concluded that he had suffered an angina attack. He was returned to his cell at 3.15pm and advised to rest and take his angina medication. At about 4.55pm Mr. Khalid was discovered lying on his bed with his eyes open and with vomit on his face. Officers commenced CPR and continued to do so until paramedics arrived about ten to fifteen minutes later. They took over the attempts to resuscitate Mr. Khalid which continued for a further twelve minutes. Throughout the procedure there was no response from Mr. Khalid. He was pronounced dead when the prison doctor arrived at 5.45pm.

Determination:
Under s.6(1)(c) the sheriff found that, in the examination of Mr. Khalid at the Prison gym, it should have been established if the chest pain of which he had complained had disappeared completely. In the absence of such a finding, the prison doctor should have been contacted and an ambulance called. However, to have done so would not have guaranteed Mr. Khalid's survival. Nor would that survival have been a probability.

Fatal Accident Inquiry into the Death of Keiran Ramsay, Sheriff Alasdair Lorne MacFadyen, Dingwall Sheriff Court, 10th March 2011

Mon, 16 May 2011 12:23:50 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Keiran Ramsay died at 00.10 hours on Sunday 17 January 2010 on the B9161 Munlochy to Artafallie Road near Bogallan, Ross and Cromarty, when the motor vehicle being driven by him left the road and collided with a tree. In terms of section 6(1)(b), the cause of death was non-survivable head injuries sustained in that collision. Formal determinations were made under section 6(1)(c), (d) and (e).

Background:
Kieran was a final year apprentice mechanic who was travelling to attend a call-out in the course of his employment when he died. He was travelling in a Volkswagen van in southerly direction along the B9161, in the Black Isle. The road, which is in the Highland Council's area of geographical responsibility, was treacherous as a result of surface ice. On the 15th January 2010, salt was applied to the B9161 to a salination level of 3, being the maximum amount of salt ever considered necessary. As there was no further rainfall in the area on 16th January, no further salting was carried out prior to the accident.

The national speed limit for cars for the B9161 was 60 mph and for vehicles such as Kieran’s van was 50 mph. At Bogallan, the van negotiated a left hand bend at a speed of no less than 66mph and then entered a straight section of road. During that manoeuvre the deceased lost control of the van, which then left the road and collided with a tree.

Determination:
Under s.6(1)(c) the sheriff found that the accident might have been avoided if the deceased had driven at a much lower speed given the prevailing icy road conditions which must have been obvious to an observant and careful driver. Under s.6(1)(d) it was held that, although ice was present on the road, there were no defects in Highland Council’s system of gritting/salination which contributed to the death. Finally, under s.6(1)(e) the sheriff noted that the deceased was not wearing a seatbelt at the time of the accident. However, given the extent and nature of the damage caused to the driver's seat area by the collision, the use of a seatbelt by the deceased would not have made any difference to the outcome of the accident.

Fatal Accident Inquiry into the Death of Colin Marr, Sheriff Principal Robert Alastair Dunlop, Dunfermline Sheriff Court, 21st April 2011

Mon, 16 May 2011 12:08:21 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Colin Marr (DOB 18.01.84) died on Tuesday 10th July 2007 in his home at 14 Johnston Crescent, Lochgelly, Fife at some point in time between 2015 and 2050 hours. In terms of section 6(1)(b), the cause of death was a single stab wound to the chest which passed through the lower part of the sternum into the chest cavity, through the pericardial sac, into the septum of the heart, through the left ventricle and terminated in the pericardial sac. A formal determination was made under section 6(1)(e).

Background:
Colin Marr was engaged to be married to Candice Bonar and the couple lived together at 14 Johnston Crescent. During the period of the engagement Colin Marr had a relationship with another woman, Roxanne Burns. Candice discovered this infidelity at some stage in the three weeks prior to Colin’s death. On the evening of 10th July 2007 Candice went to 14 Johnston Crescent to confront Colin about his infidelity. During a heated exchange she removed her engagement ring and declared that the relationship was over. At about 8.15pm Candice knocked at the door of her next door neighbour Craig Martin and then on the door of her neighbours across the street, the Emslie family, telling them that Colin had stabbed himself. An ambulance was called and first aid administered but Colin was pronounced dead from the stab wound at 8.50pm.

Determination:
In terms of s.6(1)(e) the sheriff principal found that there was no conclusive evidence to suggest that Colin Marr probably stabbed himself. It follows that there was no basis for saying that Candice Bonar probably stabbed him.

Fatal Accident Inquiry into the Death of Christina Dougall, Sheriff Ian Dunbar, Dunfermline Sheriff Court, 1st April 2011

Mon, 16 May 2011 11:57:24 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Christina Dougall died on 15th July 2009 at 3.30pm within Queen Margaret Hospital, Fife. In terms of section 6(1)(b), the cause of death was (a) acute myocardial infarction, (b) left coronary artery thrombosis, and (c) atherosclerotic coronary artery disease. Formal determinations were made under section 6(1)(c) and (d).

Mrs Dougall was admitted to QMH in March 2009 complaining of back pain following a fall. She was frail and had a number of pre-existing conditions including a heart condition. She was placed in an elderly ward but was removed to a side room as she had become disruptive to other patients on the ward. On the morning of 11th July 2009 Mrs Dougall frequently shouted for assistance and buzzed for attention. She fell from her chair while unattended and sustained a fracture. Her condition deteriorated over the following days and she died on the 15th July.

Determination:
In terms of s.6(1)(c) there were no reasonable precautions whereby the death might have been avoided. In terms of s.6(1)(d) there were no defects in any system of working which contributed to the death. There was no causal link between the fracture sustained in the fall on 11th July (or indeed the fracture of the femur sustained in the earlier fall) and Mrs Dougall's death on 15th July.

Fatal Accident Inquiry into the Death of Angus MacDonald Malone, Sheriff John Craig Cunningham McSherry, Dunfermline Sheriff Court, 14th October 2009

Mon, 16 May 2011 11:51:15 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Angus McDonald Malone died in Male Observation Cell 14, Dunfermline Police Station, Holyrood Square, Dunfermline between 00.43 and 07.55 hours on 13th August 2007. In terms of section 6(1)(b), the cause of death was the adverse effects of Morphine and Diazepam. Formal determinations were made under section 6(1)(c), (d) and (e).

Background:
Mr Malone was arrested on Friday 10th August 2007 and charged with wasting police time. Controlled drugs were found in his house. On arrival at the police station he was inadequately strip searched. Over the course of the weekend he made several statements to police to the effect that he had taken diazepam tablets and heroin which he had secreted in his rectum. He was found with faeces on his hands and had empty wrappers in his possession. However, these remarks were not correctly noted or acted upon, although a doctor did attend the deceased on the 11th August following one of his claims. The doctor concluded that Mr. Malone had not consumed drugs. Mr Malone was found unresponsive in his cell at 7.55am on the 13 August 2007. Efforts were made to revive him, but to no avail.

Determination:
In terms of s.6(1)(c), Mr Malone’s death could have been avoided if, on 10th August 2007, a thorough strip search was carried out when he was initially taken into custody. Another strip search should have been carried out on 12th August 2007 when Mr. Malone claimed to have taken drugs and to have stored them in his rectum. A search should also have been made of his cell at that time. The Force Medical Examiner should have been summoned to attend immediately to examine and question Mr Malone.

In terms of s.6(1)(d), the defects in the system of working which contributed to Mr Malone's death were: the lack of a consistent approach to the communication of information; the lack of full and accurate recording of all visits; the lack of clear guidelines when contacting an FME to attend; the lack of adequate training for Custody staff on drugs related matters; and that there was an inadequate number of Custody staff on duty.

In terms of s.6(1)(e), facts relevant to the circumstances of the death are: that his death was caused by voluntary consumption of a mixture of drugs; and that there have been improvements in custody care since the death of Mr Malone.

Fatal Accident Inquiry into the Death of Robert Shreenan, Sheriff Mhairi MacTaggart, Dumbarton Sheriff Court, 18th April 2011

Mon, 16 May 2011 11:17:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Robert Shreenan (DOB 09.01.60) died on 14th July 2008 at an indeterminate time after 18.15 hours and before 18.45 hours. The place of death was Cell 17, Clydebank Police Office, Montrose Street, Clydebank. In terms of section 6(1)(b) the cause of death was plastic bag asphyxia. A formal determination was made under s.6(1)(c).

Background:
On Monday 14th July 2008 at or about 6.30am Robert Shreenan was arrested at his home address at 11 Apple Close, Blackburn and taken to Blackburn Police Office. At 11.45am the deceased was transferred to Clydebank Police Office by Reliance officers. At that time the only bags in use on Reliance vans were clear, plastic, non-perforated bags. Mr Shreenan was nauseous during the journey and was given a plastic bag. He arrived at Clydebank Police Office at 5.45pm. The bag was not removed from him nor were custody officers advised that he had a bag in his possession. His cell was checked at 6.45pm when he was found with the plastic bag over his head and two socks tied around his neck. Emergency CPR was administered however Mr Shreenan was pronounced dead at the Western Infirmary of Glasgow at 7.38pm

Determination:
In terms of s.6(1)(c) Robert Shreenan’s death might have been avoided if Reliance officers had ensured that the plastic bag given to him was retrieved and if they had then informed custody officers at Clydebank Police Office that the bag had not been retrieved.

Fatal Accident Inquiry into the Death of Marion Bellfield, Sheriff Peter Braid, Kirkaldy Sheriff Court, 28 April 2011

Mon, 16 May 2011 11:03:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Mrs Marion Bellfield (d.o.b 22/3/49) died at 22.08 hours on 15th February 2009 at her home at 82 Chapelhill, Kirkcaldy, Fife. In terms of section 6(1)(b), the causes of death were (a) suppurative mediastanitis and pleuritis (b) endoscopic oesophogeal perforation/rupture and (c) oeosphogeal squamous carcinoma. Formal determinations were made under section 6(1)(c), (d) and (e).

Background:
On 13th February 2009 Mrs Bellfield attended the endoscopy unit at Victoria Hospital, Kirkcaldy in order to undergo an upper gastrointestinal endoscopy. It was suspected that a cancerous tumour might be present, however previous biopsy samples had tested negative. Mrs Bellfield experienced discomfort during the procedure. No evidence of cancer was found. Following the procedure the deceased developed pain in her lower abdomen and her blood pressure dropped. This was attributed to Mrs Bellfield swallowing air or pulling a muscle. An x-ray was carried out which showed no signs of air leakage. The deceased was then discharged. Her condition deteriorated over the next few days and she was attended by two different GPs on 13th and 15th February. Mrs Bellfield collapsed in her house on the evening of 15th February and was pronounced dead at 10.08pm.

Determination:
In respect of subsection (c) the carrying out of a CT scan as the first line of investigation was a reasonable precaution which might have prevented the death of Mrs Bellfield. In respect of subsection (d) there were no defects in any system of working which contributed to the death.

In respect of subsection (e), relevant facts were: that Mrs Bellfield was diagnosed post-mortem with carcinoma of the oesophagus; that her symptoms were atypical of perforation, making the perforation more difficult to diagnose; that she received adequate advice on her discharge from hospital; and that neither of the GPs who attended on 13th and 15th February 2009 had sufficient knowledge and experience of oesophageal perforations to enable them to diagnose Mrs Bellfield's perforation.

Fatal Accident Inquiry into the death of Norma Kirk [2011] FAI 15

Mon, 02 May 2011 09:51:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Mrs Norma Kirk (born 14th October 1945) died at 0825 on 27th October 2008 at Queen Margaret Hospital, Dunfermline, Fife. In terms of section 6(1)(b), the cause of death was 1.(a) chemical pseumonitis, (b) aspiration of feeding material via naso-gastric tube; 2. atherosclerotic coronary artery disease. No findings were made in terms of section 6(1)(c) or (d). Other facts relevant to the circumstances of the death were set out in terms of section 6(1)(e).

The deceased was admitted to Queen Margaret Hospital on 11th July 2008, for surgery on a perforated abdominal ulcer, where she developed post-operational complications including pneumonia. On 1st September 2008, naso-gastric feeding was established and on 30th September, the decision was made to feed her overnight. On 23rd October, feeding was due to commence but a Staff Nurse and an Advanced Nursing Practitioner were both unable to obtain gastric aspirate. A chest x-ray was therefore requested. The x-ray was erroneously interpreted by both a junior doctor and a Senior Registrar, as showing the naso-gastric tube correctly positioned in the stomach. Naso-gastric feeding and medication then commenced on 24th October. At 0545, Mrs Kirk was found to be distressed with breathing difficulties and at 0550, the naso-gastric feed was discontinued and oxygen therapy commenced. A further x-ray was requested. At 0845 a Consultant Geriatrician reviewed the earlier x-ray and determined that a tube was located in the right pleural cavity with accumulation of fluid believed to be naso-gastric feed. A Consultant Radiologist and Consultant Physician reviewed both x-rays and came to the same conclusion. Mrs Kirk deteriorated over the following days and was pronounced dead at 0825 on 27th October.

Submissions for the Crown included criticisms of the lack of training in the insertion of naso-gastric tubes, absence of written instruction to call for x-ray when no aspirate was obtained, lack of contemporaneous notes and that there was no check on doctors’ expertise in reading x-rays, with the Sheriff invited to make a finding under section 6(1)(e). Submissions on behalf of the doctors who misread the x-ray invited findings under section 6(1)(a) and (b). It was accepted that the Senior Registrar’s ultimate decision to proceed with the naso-gastric feed was erroneous. Submissions for the Staff Nurse also invited findings under section 6(1)(a) and (b), as did submissions for Fife Health Board, which referred to staff’s adherence to the protocol in place at the relevant time and subsequent changes to protocol and training.

Having heard evidence, the Sheriff set out his conclusions in respect of the cause of death. The Sheriff also set out the other relevant facts regarding changes made in respect of protocol, night-time feeding and training in interpreting x-rays since Mrs Kirk's death, while indicating that he did not accept any other direct cause of death than a clinical error of judgement in misreading the chest x-ray. The Sheriff did not criticise the fact that the new protocol document dealing with several matters including those mentioned in this case, was still in draft form and highlighted that it was not a matter to be rushed, particularly as the new protocol in respect of the matters raised in this case was already being followed. He highlighted that no matter how comprehensive training may be, there is always the possibility of human error.

Fatal Accident Inquiry into the circumstances of the death of Alexander Ogg Wylie [2011] FAI 12

Sun, 24 Apr 2011 15:08:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Alexander Ogg Wylie died on 27th December 2009 at 22.55 at Ninewells Hospital, Dundee. In terms of section 6(1)(b), the cause of death was atherosclerotic coronary artery disease, with minor blunt force injuries being a contributory factor.

The deceased, a 46 year old taxi driver, was in police custody at the time of death, having been detained in connection with an earlier disturbance. On arrival at Tayside Police Headquarters, Dundee, he became unwell in the police vehicle and stopped breathing. Police officers attempted to administer first aid, carried out chest compressions and requested urgent medical assistance. A rapid response vehicle and ambulance attended almost immediately. Further attempts were made to resuscitate Mr Wylie but these were unsuccessful. He was taken to the Accident & Emergency Department of Ninewells Hospital, where it was noted that he had no pulse and indications were consistent with cardiac arrest. Normal procedure for cardiac arrest patients was followed, with several attempts made to resuscitate Mr. Wylie. Ultimately, however, he was found to be asystolic, showing no heartbeat and in cardiac arrest. Doctors agreed further efforts to resuscitate him would have been futile and he was pronounced dead at 22.55.

A post mortem examination was conducted on 29th December 2009 and it was recorded that death was attributed primarily to atherosclerotic coronary artery disease. The inquiry also heard evidence that any involvement in an altercation and minor blunt injury would be viewed as significant contributory factors, and that while the injuries themselves would not have been fatal, the sequence of events strongly suggested that the stress associated with the altercation precipitated death from pre-existing natural disease.

Submissions for the Crown and Tayside Police were made requesting that the Sheriff return a formal verdict. On behalf of Tayside Police, the Sheriff was asked to accept that police officers did everything they possibly could to assist Mr. Wylie. Submissions were also made on behalf of Tayside Health Board, asking the Sheriff to hold that the medical care provided to Mr. Wylie was entirely appropriate to the circumstances of his condition.

Having heard evidence, the Sheriff noted the circumstances of Mr. Wylie's death were extremely unfortunate. The Sheriff took the view that the police officers involved, paramedics and doctors who tried to save Mr. Wylie did everything that could have been asked of them in their professional capacity. He accepted the doctors’ evidence on the procedures carried out and that nothing further could have been done to save Mr Wylie. He also accepted the results of the post-mortem examination and evidence heard that the absence of nurses from the cell area at police headquarters when Mr. Wylie took ill would have had no effect on the outcome. It was held that there were no reasonable precautions which could have been taken which might have avoided Mr. Wylie's death, no defects in any system of working which contributed to his death and no other facts relevant to the circumstances. Accordingly, no findings were made in terms of section 6(1)(c), (d) and (e).

Fatal Accident Inquiry into the Death of Bryan Ross, Sheriff Neil Douglas, Paisley Sheriff Court, 23rd February 2011

Sat, 09 Apr 2011 21:19:45 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Bryan Ross died at the Kibble Educational and Care Centre, Goudie Street, Paisley, sometime around midnight on 20th/21 July 2009 and was pronounced dead at 0210 hours on 21 July 2009. In terms of section 6(1)(b), the cause of death was hanging. Formal determinations were made under section 6(1)(c), (d) and (e).

Bryan was a thirteen year old boy at the time of his death. He came from a troubled background and had behavioural problems. He resided at the Kibble secure residential facility from 27th March 2009 until his death. Around midnight on 20th/21st July 2009 Bryan hanged himself in his secure bedroom by means of a ligature formed from his dressing gown. Bryan should not have been left with his dressing gown in his bedroom overnight and its removal was overlooked. His body was discovered as a result of a routine check. Checks should have taken place every fifteen minutes from bedtime until midnight. The checking on that evening was of a lesser frequency. There were no signs during his time at Kibble that he would consider acting in the way he did. Accordingly, it was not established that Bryan intended to kill himself.

Determination:
Under section 6(1)(c) made the sheriff made two findings. First, staff members should have ensured that Bryan's dressing gown was removed and placed in a locked cupboard. However, other material in the room, such as bedding, could have been used as a ligature therefore it was impossible to find that the removal of the gown would have prevented death. Second, staff should have carried out fifteen minute observations until midnight. However, even if this had occurred it may not have affected the outcome.

Under section 6(1)(d) the sheriff found that the absence of a written policy on the frequency of observations was not a defect as the orally communicated policy was reasonably clear to staff members. Under section 6(1)(e) the sheriff found that there was no causal connection between the matters which might be raised under this section and the death.

Fatal Accident Inquiry into the death of Jessie Gillespie Taylor [2011] FAI 9

Fri, 01 Apr 2011 14:45:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Mrs Jessie Taylor died at 0845 on 20th September 2009, at Queen Margaret Hospital, Dunfermline, Fife. In terms of section 6(1)(b), the cause of death was multi-organ failure due to streptococcal sepsis and right lung pneumonia.

The deceased became unwell in September 2009, suffering from flu-like symptoms and thereafter diarrhoea, fever and vomiting. On Friday 18th and Saturday 19th September, her partner called NHS24 and received advice from the flu line, set up in response to the swine flu pandemic. A call-back from a GP was arranged and the deceased was advised to attend the Out of Hours GP Clinic at the Victoria Infirmary that afternoon. Following a preliminary diagnosis of gastroenteritis, the deceased was admitted to Ward 7 (infectious diseases). At 1545, she was seen by a doctor who made a preliminary diagnosis of swine flu. The doctor was unable to administer intravenous fluids and called for assistance from the Intensive Care Registrar. The Intensive Care Registrar, who arrived at around 1700, noted the deceased’s condition had deteriorated. He was also unable to obtain access to administer fluids and discussed the problems with the Medical Registrar. At 1800 the Consultant arrived, and he diagnosed either a viral or bacterial pneumonia and ordered a chest X-ray and antibiotics. An intravenous line had, by then, been secured. Care was passed to a Consultant Anaesthetist, who started a central line, and antibiotics commenced at 1930. After consultation with the High Dependency Unit at Queen Margaret Hospital, the deceased was transferred there, arriving at about 0025. She received further treatment and was initially stable but then began to deteriorate, and died at 0845.

The Inquiry was held against the background of concerns expressed by the deceased’s family and the question of whether swine flu ‘hysteria’ influenced her treatment. It was submitted for the family and the Crown, that there were a number of areas to be scrutinised. These were, firstly, the GP’s decision not to admit Mrs Taylor directly to A&E after speaking with her on the telephone at 1122; secondly, the GP’s decision to admit the deceased to Ward 7 and not A&E after consultation at 1430; and thirdly the delay in the administration of treatment in Ward 7.

Having heard evidence, the Sheriff noted that with the benefit of hindsight, it would have been beneficial for the deceased to have been sent to A&E, but made no criticism of the GP’s decision to see her at the Clinic, which in light of underlying fears of swine flu, was reasonable and professional. Further, the Sheriff did not consider the decision to admit to Ward 7 could be criticised, based on the symptoms presenting at the time. In respect of the issue of delay in Ward 7, the Sheriff considered that the evidence as a whole gave the impression of delay (although it was inappropriate to compare the likely speed of treatment in A&E, given the finding that admission to Ward 7 was reasonable). The Sheriff did not consider that there were any reasonable precautions which could have been taken in terms of section 6(1)(c), nor defects in the system of working in terms of section 6(1)(d).

In respect of submissions under section 6(1)(e), the Sheriff considered the evidence did not support the submission that admission to a Ward on a Saturday afternoon increased the likelihood of delay. Further, although he accepted, to some extent, that the swine flu background to the case changed the way the deceased was dealt with, decisions were correctly taken at the time. Given the restricted wording of section 6(1)(e) and that it could not be said with any degree of certainty that the death could have been avoided by earlier treatment, the Sheriff did not make any finding in respect of delay under that section.

Fatal Accident Inquiry into the death of Lewis MacDonald [2011] FAI 6

Fri, 25 Mar 2011 21:04:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Lewis MacDonald died at approximately 8.50am on 28th November 2008, as a result of a fall from the deck of the Ocean Princess drilling rig, berthed in Invergordon.

In terms of section 6(1)(b), the cause of death was the deceased crossing a solid barrier on to a badly corroded section of grating which could not bear his weight, causing him to fall approximately 100 feet through the deck to the sea below, striking a structural cross-member of the rig during his fall. The deceased sustained extensive serious injuries to his head, chest and abdomen, resulting in instant death.

On the date of death, the deceased was employed as a scaffolder by MacDonald Scaffolding Services Limited, who were contracted to carry out scaffolding works on the rig by Diamond Offshore Drilling (U.K.) Limited. Refurbishment and maintenance work required the movement of a metal workshop container, which exposed an area of corroded grating. A hung scaffold was erected under the exposed area on 27th November 2008. On 28th November, the scaffolding was extended to barrier off the whole exposed area. Upon inspection of the scaffolding, the foreman scaffolder directed his squad to loosen horizontal handrails which were protruding into the landward walkway and to slide them seawards. The deceased loosened the seaward couplings and climbed over the top handrail, landing on the uncovered area of exposed grating. The grating collapsed under his weight, causing his fall.

Having heard evidence from other scaffolders including the foreman, as well as an inspector with Health and Safety Executive, the Sheriff found that the deceased had died as a result of a tragic accident. The accident was occasioned by the unexplained actions of the deceased, which the Sheriff considered were unforeseeable in all the circumstances. The Sheriff did not consider that either MacDonald Scaffolding Services or Diamond Offshore Drilling should have taken any other precautions to avoid an accident and did not make any findings in terms of section 6(1)(c), (d) or (e).

Inquiry Under the Fatal Accidents and Inquiries (Scotland) Act 1976 into the Sudden Death of Danielle Welsh, Sheriff Andrew M Cubie, Glasgow Sheriff Court, 2nd February 2011

Mon, 21 Mar 2011 16:21:00 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Danielle Welsh died on 24th June 2008 at 10.25am at the Royal Infirmary of Edinburgh. In terms of section 6(1)(b), the cause of death was Liver failure due to paracetamol toxicity caused by iatrogenic paracetamol overdose. Formal determinations were made under section 6(1)(c), (d) and (e).

Background:

Danielle was 19 at the time of death and suffered from an unidentified condition causing spondyloepiphyseal dysplasia, short stature, mild but longstanding learning difficulties, problems with hearing and chronic pain. At June 2008 she weighed 35kg.

On 15th June 2008 Danielle became unwell and was taken to the Southern General Hospital. She was prescribed intravenous paracetamol at a dose of 1g four times daily. This was prescribed by a junior doctor who did not check Danielle’s weight. She should have received 525mg per dosage. Danielle received 20 such doses over five days during which her condition was monitored by 21 clinicians. None of these individuals knew that paracetamol was prescribed differently if administered intravenously and if the patient weighed less than 50kg.

Determination:
With the exception of the paracetamol overdose, Danielle received attentive, focused and appropriate care. However, there was a gap in the knowledge of all those who prescribed, administered, reviewed and considered the intravenous paracetamol prescription.

Under s.6(1)(c) the sheriff found that Danielle’s death could have been avoided if: the prescribing doctor had checked the British National Formulary (BNF) before prescribing intravenous paracetamol; the nursing staff administering the drug had checked that the dosage was appropriate for Danielle’s weight; and the pharmacist had checked the BNF when reviewing the prescription. Under s.6(1)(d) the sheriff found that there were no defects in the system of working which contributed to Danielle’s death. Under s.6(1)(e) the sheriff found that there was a culture of assumed familiarity with intravenous paracetamol which was misplaced.

A number of recommendations about procedures for prescribing intravenous paracetamol were made by parties. These were rejected by the sheriff on the basis that they were outwith the scope of the hearing.

Fatal Accident Inquiry into the circumstances of the death of Paul Rainey [2011] FAI 3

Sat, 12 Feb 2011 19:30:07 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Paul Rainey died on 12th April 2008 at 15.41 at the Victoria Infirmary, Glasgow. In terms of section 6(1)(b), the cause of death was undetermined. Formal determinations were made under section 6(1)(c), (d) and (e).

The deceased, who had a history of alcohol and drug abuse and suffered from alcohol withdrawal seizures, was in police custody at the time of death. He was arrested and taken to Cathcart Police Office, Glasgow on 11th April 2008. On 12th April at approximately 14.50, he activated his cell buzzer and was found lying motionless by police staff. Although initially breathing with a faint pulse, the deceased then stopped breathing and had no detectable pulse. Despite efforts to resuscitate him in his cell and thereafter in an ambulance, he was pronounced dead at 15.41 at the Victoria Infirmary.

A post mortem examination was conducted and the forensic pathologist listed the cause of death as ‘undetermined’ pending investigations. Her subsequent report repeated that finding and concluded that whilst no definite cause of death was identified, the possibility of death as a result of alcohol withdrawal complications had to be considered. Expert evidence was heard at the Inquiry, however, that the deceased could not have been suffering from a seizure when he activated the cell buzzer, or between then and the time he was found in his cell. On the basis of this evidence, all parties confirmed in their submissions that the cause of death could no longer be challenged successfully and requested formal determinations under section 6(1)(c), (d) and (e).

Submissions were made for the deceased’s family that the section 6(1)(a) determination should state that he died between 14.56 and 15.19 within Cathcart Police Station. The Sheriff rejected these submissions and concluded that on the evidence, he must give effect to what was stated in the death certificate.

Fatal Accident Inquiry into the circumstances of Mr John Henry Crosbie [2011] FAI 5

Sun, 23 Jan 2011 20:48:58 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Mr John Henry Crosbie died in HMP Barlinnie, 81 Lee Avenue, Glasgow on 17 April 2009. The cause of death was ischaemic heart disease due to coronary artery atheroma.

The court heard that the deceased had no significant past medical history and was apparently in reasonable health. The deceased was admitted to HMP Barlinnie on 16 April 2009, to serve a six month imprisonment. On his admission, he was examined by various members of medical staff, but there were no concerns about his health and he made no complaint about his health. On his second day in prison, the deceased made a telephone call, during which he collapsed. Despite efforts by staff and medical officers to resuscitate Mr Crosbie, he was pronounced dead at 16.13.

A post-mortem examination found that the deceased died of natural causes as a result of ischemic heart disease due to severe coronary artery disease. The court heard that this condition could have resulted in sudden death and collapse at any time.

Accordingly, the Sheriff found that in terms of sub-sections 6(1)(c), (d) and (e), there were no circumstances of the death to be set out.

Fatal Accident Inquiry into the circumstances of the death of Linda Anne Murdoch or Weir [2011] FAI 2

Sun, 23 Jan 2011 19:44:15 GMT

In terms of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 section 6(1)(a), the Sheriff found that Linda Anne Murdoch or Weir died on 5 April 2010 in a drowning accident at Burnsands burn, Crairieknowe Farm, Thornhill, Dumfrieshill, while engaged in her occupation as a farmer.

The Sheriff recorded that the cause of death was drowning, following an accident when the deceased was attempting to cross the burn in an all-terrain vehicle quad bike. At this time, the stream was grossly swollen with fast moving water. The court heard that the burn was normally around six inches deep and could be easily crossed using a quad bike. Following heavy rain however, on the date of death the burn had a fast flowing depth of approximately two and a half feet. The Sheriff ruled that it was likely that the deceased had misjudged the depth of the burn on the day of the accident and had been swept away from the vehicle.

The Sheriff found that there were no defects in any system of working which contributed to the deceased’s death and the accident resulting in her death.

Fatal Accident Inquiry into the circumstances of the death of Mr William Stewart [2011] FAI 1

Tue, 18 Jan 2011 19:14:26 GMT

In terms of section 6(1)(a) of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Mr William Stewart died at 1911 hours on 19th February 2008 within Cell 49, Abercrombie Flat 5, Glenochil Prison, King O'Muirs Road, Tullibody. The cause of death was Artheroscleoric Coronary Artery Disease.

The court heard that the deceased was serving a life sentence imposed in 1993 at the time of his death. He had a history of heart disease, and had already suffered one heart attack. The Sheriff noted that the deceased had made a well documented choice not to take medication prescribed for his condition, contrary to medical advice.

The court heard that the deceased was found in a collapsed state lying on his bed in his cell, by a fellow inmate at 1845 hours on the date of death. Attempts were made to resuscitate him by prison officers, prison medical staff and paramedics, but these attempts were ultimately unsuccessful and the time of death was recorded as 1911 hours.

The Sheriff did not make any recommendations under sub-sections 6(1)(c), (d) or (e) of the Act. The Sheriff instead complemented the Scottish Prison Service staff, and in particular the medical staff, for the quality of care and medical treatment shown to the deceased during his lifetime.

Fatal Accident Inquiry into the circumstances of the death of Mr Alexander Stewart [2010] FAI 52

Tue, 04 Jan 2011 22:54:53 GMT

Having heard evidence and submissions, the Sheriff found that in terms of section 6(1)(a) of the Fatal Accidents and Sudden Death Inquiries (Scotland) Act 1976 that Mr Alexander Stewart, whose date of birth was 2nd November 1937, had died at 13.19 hours on 1st August 2008 within Belford Hospital, Fort William. The cause of death was: (a) traumatic disruption of the liver; and (b) compression injury by a mechanical shovel. The deceased’s injuries were suffered by him in the course of his employment with Lorne Developments Limited trading as Lochaber Aggregates, Ben Nevis Industrial Estate, Fort William.

The court heard from employees who gave evidence to the effect that the deceased had joined another employee on top of a screening plant and was stepping back on to the hydraulic bucket lift which he had used to ascend the structure, when he was tipped against it and caught between the two structures.

In terms of section 6(1)(c) of the Act, the Sheriff found that there were a number of reasonable precautions whereby the death of Mr Stewart might have been avoided. These were:

(a)    That the bucket/loading shovel should not have been used for lifting personnel.
(b)   That the operator of the bucket lift should not have leaned out the right hand side door of the vehicle.
(c)    That the operator having decided to lean out of the right hand side door should have used the hydraulic lock switch in the cab thus preventing any non intentional movement of the hydraulic arm and bucket/loading shove.
(d)   That the bucket/loading shovel should not have been in use without a working parking brake.
(e)That Alexander Stewart ought not to have been on top of the screening plant.

Moreover, in terms of section 6(1)(d) of the Act, the Sheriff found that the defects in systems of working which contributed to the death or any accident resulting in the death were as follows: (a) The vehicle should not have been used to lift the screening plant. It was not intended for lifting operations. It did not have an overload warning device or check valves fitted. (b) A proper assessment of the weight of the screening plant to be lifted and the load capabilities of the vehicle should have been carried out. (c) Had such an assessment been carried out it would have been ascertained that an excavator intended for and suitable for this type of lifting operation or a mobile crane should have been used. (d) A ladder or mobile elevated work platform should have been used to gain access to the top of the screening plant.

Fatal Accident Inquiry into the circumstances of the death of Mrs Jean Elizabeth Wilson [2010] FAI 53

Sun, 02 Jan 2011 21:45:03 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 the Sheriff found that Mrs Jean Elizabeth Wilson, date of birth 19 June 1939, had died in Monklands District General Hospital at 5.20 pm on 30 September 2006. The Sheriff found that in terms of section 6(1)(b) that the cause of her death was Multiple Organ Failure and Sepsis following Femoral Angioplasty carried out on 19 September 2006 and a significant blood loss into the tissues which occurred after 21 September 2006.

Having heard evidence on the deceased’s medical procedures leading up to her death, and in particular, her kidney problems, the Sheriff concluded that there were a number of reasonable precautions which might have been made, whereby Mrs Wilson’s death might have been avoided.

Firstly, the Sheriff found that an assessment of the state of Mrs Wilson's kidney function prior to a CT angiogram could have been out in Monklands District General Hospital on 12 July 2006 by means of taking a blood sample and the analysis of that by the Biochemistry Department. Secondly, there could have been an institution of steps to help improve Mrs Wilson’s kidney function prior to her angioplasty e.g. encouraging an increase in the intake of fluids, the adjustment of her medication and the taking of further blood tests to assess her continued renal condition. Thirdly, the Sheriff also found that there also should have been a system in place whereby the Radiology Department had access to Mrs Wilson’s blood results.

In terms of section 6(1)(d), the Sheriff found defects in the system of working which contributed to the deceased’s death by the medical professionals attending to her, but noted that these defects had all been subsequently addressed by NHS Lanarkshire.

Fatal Accident Inquiry into the circumstances of the death of Mr Michael Lindley Scott [2010] FAI 49

Mon, 06 Dec 2010 21:09:38 GMT

In terms of section 6(1)(a) of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 2000, the Sheriff found that Mr Michael Lindley Scott died on 13 December 2006, following an accident which occurred before or around midday on the same day, at premises known as the Old Mill, York Place, Aberdeen. At the time of his death, the deceased was employed as an apprentice plumber. The cause of death was traumatic asphyxia, whereby his chest and neck were compressed by a considerable weight of MDF.

On 13 December 2006, the deceased arrived at his work premises at an unknown time, and neither his boss nor other employees had yet arrived. The deceased was alone in the building at the relevant time and had been instructed by an email from his boss to “tidy up upstairs”. When the deceased’s employer arrived on the premises at around midday, he found the deceased pinned against the right wall of the ground floor corridor by 20 sheets of MDF. An ambulance was called and the MDF was removed. Attempts to resuscitate the deceased were unsuccessful, and the deceased was later pronounced dead at 12:52 at Aberdeen Royal Infirmary.

The Sheriff noted that as the deceased was alone in the building, it seems that he had decided to move at least one of the planks of MDF himself, but for what reason and how he attempted to do so, it was impossible to say. The Crown invited the court to make a recommendation that suppliers of MDF should give a warning printed or stamped on each sheet advising that MDF should be stored flat. In submissions for the employer, the court was not invited to make this recommendation, as there was no evidence to show that the deceased’s employers had done something, or had failed to do something, whereby the accident could have been prevented; it was simply impossible to say how the accident had occurred.

The Sheriff decided not to make the Crown recommendation as such a recommendation could only be made if the court was satisfied that the accident might have been avoided had the warning been on the sheets at the time. The Sheriff noted that it was not possible to say, on the basis of the evidence, how the accident took place and it would therefore not be sensible or appropriate to say that a warning might have prevented it.

Secondly, the Sheriff noted that the recommendation, if made, would, sensibly, have to relate not only to MDF, but other material such as plasterboard and plywood. Other things such as doors and windows which might present similar hazards could not be excluded. The Sheriff concluded that a wide-ranging investigation would be needed to identify all such material and noted that this was not the function of an FAI.

Thirdly, the Sheriff noted that many people currently purchase MDF, plywood etc for DIY purposes, and accordingly, the cost and transport implications of such a warning would need to be considered in more depth; this was again a function not appropriate for a FAI.

The Sheriff therefore found that there were no reasonable precautions which could have been taken by the deceased’s employers whereby his death might have been avoided, and there were moreover no defects in the system of working which contributed to the death or the accident resulting in the death.

Fatal Accident Inquiry into the circumstances of the death of Mr Craig Lochrie [2010] FAI 48

Mon, 06 Dec 2010 21:04:00 GMT

In terms of section 6(1)(a) of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 2000, the Sheriff found that Mr Craig Lochrie died Monklands District General Hospital on 9 June 2008 at 1210 hours. The cause of death was (a) crush injuries to chest and abdomen due to (b) an industrial accident.

On the date of death, the deceased was working for his employers at a scrap yard. The deceased was employed as a scrap metal burner and his job was to cut large pieces of scrap metal down to smaller sizes. The deceased was working on site in a designated area on inter alia a plate lift mechanism. The lifting beam of the plate lift on which he had been then working, toppled forward and fell on the deceased, trapping him against a railway chassis causing crush injuries to his chest and abdomen. Eyewitnesses attempted to remove the lifting beam from the deceased but were unable to do so. While one colleague radioed for an ambulance, another helped in the removal of the lifting beam, assisted with chains and a crane.

At the inquiry, it was not in dispute that the deceased must have been standing between the legs of the plate lift at the time the lifting beam toppled forward, trapping him against the upturned chassis. What was not clear was why the deceased might have been there. Witnesses from the deceased’s place of employment gave evidence to the effect that the only safe way to burn metal was outside of the legs of the plate lift, and that moreover, the deceased would have known this as an experienced burner. Evidence also suggested that the deceased was not careless with his safety and would not have deliberately jeopardised his well-being by standing in the middle of the plate lift while still burning. Therefore, one reasonable hypothesis was that the deceased had stopped burning at the time and had turned to work on materials behind him. However, given that there was no evidence to support this, the Sheriff concluded that it was not possible to state beyond doubt why the deceased had placed himself in the middle of the plate lift.

Accordingly, under section 6(1)(c) of the 2000 Act, the Sheriff determined that a reasonable precaution whereby the deceased’s death might have been avoided was for the deceased not to place himself in the area inside the legs of a plate lift mechanism, on which he had been working at the time of the accident.

Fatal Accident Inquiry into the circumstances of the death of Mr Peter Drysdale [2010] FAI 51

Thu, 02 Dec 2010 23:36:49 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that on 8th September 2009 at approximately 1100 hours Peter Drysdale died at Dalbeathie Farm, Dunkeld, as the result of an accident there. The cause of death was multiple injuries and blunt force trauma resulting from entrapment by the hydraulic mechanism of an agricultural trailer.

The deceased was a member of a well-known farming family, which he ran with his son, Mr Drysdale Jnr. The farm had an employee, Mr Simpson. On the day in question Mr Drysdale Jnr and Mr Simpson were storing barley in one of the farm sheds, an annual task carried out every winter. The barley was in a trailer, attached to a tractor that had been placed in the shed. The trailer had metal sides, and was raised and lowered by means of two hydraulic arms. The tailgate was also raised and lowered by means of hydraulic arms attached to either side of the trailer. When the tailgate was lowered, its lip made a tight seal with the trailer platform, thereby preventing the contents from escaping. The trailer and tailgate were operated independently by separate spool valves or levers at the right hand side of the tractor cab. They could not be operated from the back of the trailer.

At approx.1100 hours both men were involved in tipping the load from the trailer onto the floor at the back of the shed, where a large pile of grain was already stored. After Mr Simpson had tipped half the load onto the floor, with Mr. Drysdale watching, he then lowered the trailer and moved it forward slightly. At this point he exited the cab for the first time, and the two men proceeded to clean the trailer area next to the tailgate with their hands. The cleaning operation took them about 10 to 20 seconds. It was during the tipping operation that the deceased walked into the shed.

When they were finished, Mr. Simpson returned to the tractor to move the trailer outside the shed. The tractor engine was still running. This particular operation involved lowering the trailer completely before closing the tailgate and then driving forwards. It was the men's intention to raise the trailer platform outside and allow the remainder of the grain to slide to the rear before returning the trailer to the shed. After operating the levers, it took Mr. Simpson in total about ten to fifteen seconds to lower the trailer completely and about five or six seconds for him to close the tailgate. However, as the tractor passed Mr Drysdale Jnr he became aware that his father had become caught in the tailgate at the nearside of the trailer. The deceased's feet were about six to eight inches off the ground and all that Mr Drysdale Jnr could see were his legs. The rest of his body was within the trailer compartment. The deceased was later pronounced dead upon the arrival of the emergency services.

The Crown submitted that there was no question that the deceased had died as a result of an accident, which involved being crushed between the tailgate and the back end of the trailer. What was not known was how he came to be in contact with the tailgate in the first place. Mr Drysdale Jnr was unable to say how the deceased came to be caught in the tailgate; he thought that his father might have seen some barley still lying at the rear of the trailer and tried to remove it. Mr. Simpson also commented that the deceased was "quite careful", and his guess was also that he was trying to help by clearing grain from the rear when the tailgate came down. The Sheriff accepted that this was the most likely explanation and inference, but noted that it could not be supported by direct evidence.

In order to prevent future accidents, in terms of the section 6(1)(e) of the Act, the Sheriff noted that the other facts relevant to the circumstances of death were (a) the absence of any audible warning system when the tailgate was being raised or lowered and (b) the absence of any sensory system to halt the movement of the tailgate on detecting an object immediately below it. The Sheriff recommended that the manufacturers of such equipment consider the introduction of these possible safety systems to prevent future similar tragedies occurring.

Fatal Accident Inquiry into the circumstances of the death of Mr James McNeill [2010] FAI 50

Thu, 02 Dec 2010 23:33:21 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Mr James McNeil (DOB 14th September 1935) died at 08:30 hours on the 22nd of October 2008 at Belhaven Hospital, Dunbar. The cause of death was (i) bronchopneumonia; (ii) pressure sores on back, ischemic heart disease, and dementia.

In 1989, Mr McNeill was diagnosed with Alzheimer’s disease, and his condition eventually deteriorated in 2007. On 18th April 2008 Mr McNeill was admitted to Lennel House Nursing Home, Coldstream; Lennel House was a nursing home owned and operated by Guardian Care Homes (UK) Ltd. On admission to Lennel House an Admission Assessment Form was completed by the duty staff nurse. The assessment covered, inter alia, the risk of pressure sores; Mr McNeill was assessed as being at high risk of developing pressure sores.

On 19th May 2008 two blood blisters were noticed on Mr McNeill's sacral cleft. These were the first manifestations of the early stages of pressure sores. In the course of the following days the blisters were treated with creams and dressings. However, the area of the wound, which was measured and recorded daily, increased. By 30th May 2008 the blisters measured 3 x 1.5cm and 1 x 1cm and were recorded as being necrotic and producing an odour, signs consistent with infection. By 9th June 2008 the measures put in place produced no improvement and the odour from the wound was now described as offensive. On 11th June 2008 the district nurse visited Lennel House by prior arrangement. The wound now measured 13 x 4.5cm and was discharging thick yellow puss. A hole had appeared in the sacral cleft from which fluid leaked. The district nurse arranged for Mr McNeill to be examined by a GP which examination was conducted on 12th June 2008. As a result of this examination the GP arranged for Mr McNeill to be admitted to the Borders General Hospital on 12th June 2008 in order to obtain a surgical opinion. On 13th June 2008 surgical debridement of Mr McNeill's pressure sore wound was carried out. The operating surgeon considered the wound to be serious and described the operation as a "planned emergency". In his experience of having carried out 12 or so pressure sore debridements over the years, this was described as the worst which he had encountered.

Mr McNeill remained at Borders General Hospital until 24th September 2008 when he was transferred to Roodlands Hospital, Haddington. On 20th October 2008 Mr McNeill was transferred to Belhaven Hospital in Dunbar. At about 06:00 hours on Wednesday 22nd October 2008 nurses attended on Mr McNeill to administer medication, including morphine sulphate, and prepare him for a bed bath. After about 30 minutes, when in course of being bathed, Mr McNeill's condition deteriorated and he expired in the presence of nursing staff.

The Sheriff noted that from the evidence there could be little doubt that Mr McNeill’s care at Lennel House would have benefitted from better and more promptly implemented care plans and risk assessments; from being cared for by nursing staff who had the advantage of better managerial support; better induction procedures; better training especially in respect of pressure sores and the care of the elderly; better dissemination of information regarding policies and procedures; better access to specialist equipment; and from allocated time for communication as between staff on different shifts.

Focusing on Mr McNeill's development of pressure sores, the risk of these developing would almost certainly have been reduced with earlier provision of special mattresses, cushions and organised and recorded positional changing. The Sheriff concluded from the evidence that the latest date when Lennel house nursing staff ought to have contacted the district nurse, or general practitioner, regarding Mr McNeill's pressure sore would have been 4th June 2008. However, the Sheriff noted that in the interim period, key staff had changed at the nursing home and that following the death of Mr McNeill, procedures had been improved radically. For these reasons, the Sheriff considered it inappropriate to make any findings under the Act in terms of section 6(c) and (d).

Fatal Accident Inquiry into the circumstances of the death of Mr Gavin McCabe [2010] FAI 47

Sun, 14 Nov 2010 22:17:14 GMT

In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff found that Mr Gavin McCabe died at 17.20 hours on 21 March 2009, at Ninewells Hospital, Dundee, as a consequence of injuries sustained when a motor vehicle driven by him was involved in a collision. The vehicle was driven by the deceased in the course of his employment as a taxi driver. The Sheriff found that Mr McCabe's death was the result of multiple injuries sustained by him as a result of the collision, including blunt force trauma when he was ejected from the vehicle and hit the road.

Under section 6(1)(c), the Sheriff noted that Mr McCabe was not wearing a seatbelt at the time of the collision. The Sheriff ruled that a reasonable precaution would have been for Mr McCabe to have been wearing a seatbelt, and had he been wearing such a seatbelt, his death may have been avoided.

The Sheriff noted that taxi drivers are presently exempt from wearing seatbelts under regulation 6(1)(g) of the Motor Vehicles (Wearing of Seatbelts) Regulations 1993 (SI 1993/176). This exception was originally lobbied for by the industry, in order to protect taxi drivers from escaping robbery or attack when transporting strangers.

Agreeing with the submissions made by the Crown, the Sheriff agreed that the appropriate government authority should review these Regulations, in order to determine whether the rationale underlying the exception was still sound. The Sheriff noted that the exception was particularly misguided nowadays, considering that the majority of taxi cabs now have isolated driver booths, protecting them from any risk of robbery or assault. Moreover, the Sheriff saw no need for the exception when the taxi is not transporting a passenger.

The Sheriff noted that the risks to the health and safety of both drivers and passengers under the current Regulations were wholly disproportionate to the perceived risks to drivers of physical abuse. The Sheriff concluded that the Scottish Ministers and the Secretary of State for Transport should urgently review the current regulations, with a view to rescinding the exception, either entirely, or at least to amend it to no longer apply to Hackney cabs etc, or to private hire cabs when they have no passengers.

Fatal Accident Inquiry into the death of William Casuga Antonio [2010] FAI 46

Thu, 04 Nov 2010 23:09:25 GMT

In terms of section 6(1) of the Fatal Accidents and Sudden Death Inquiry (Scotland) Act 1976, the Sheriff determined that William Casuga Antonio died at approximately 18:50 hours on 11 November 2009, in the North Sea approximately 5.5 miles off Macduff, Aberdeenshire. Mr Antonio died in the course of his employment as a deckhand, on the fishing vessel Osprey III. The cause of death was drowning. The Sheriff determined that Mr Antonio died after becoming entangled in fishing net as it ran from the rear deck of the vessel, and he was then carried overboard by the net.

Having heard evidence, the court determined that Mr Antonio’s death might have been avoided had the Osprey III been carrying suitable, well maintained lifejackets available to the crew for them to wear during net shooting and hauling operations. The court further noted that Mr Antonio’s death might have been avoided through the crew practicing “man overboard” drills, in order to ensure the crew had a good understanding of the effects on the human body from immersion in cold water, survival within the water, how to potentially recover a crew member from sea, and how to effect such a rescue successfully. The court finally noted that Mr Antonio’s death might have been avoided had the Osprey III crew also been provided with a properly positioned life saving “cage”, to facilitate his recovery from the water.

In terms of section 6(1)(e), the court recommended that fishing vessel owners should encourage the use of suitable lifejackets by crew members when on deck during net shooting and hauling and other dangerous operations unless such lifejackets are seen to represent, in any particular situation, a risk to the wearer. The court further recommended that (a) skippers should be trained with regard to the effects of cold shock on the human body; (b) skippers should be trained as to the extent to which crew members require to obtain "health and safety training" and ensure that such training has taken place; and (c) the health and safety training of such crew members should include training as to the effects of cold water shock on the human body.

Fatal Accident Inquiry into the death of Ms Carrie Helen Anderson [2010] FAI 45

Thu, 04 Nov 2010 22:19:33 GMT

Having heard evidence and productions led, the Sheriff concluded that Carrie Helen Anderson died on 23 February 2010 on the C410 Huntingtower to Crieff Road at its junction with C460 Gorthy to Auchterader Road, as a result of a road accident.

The Sheriff concluded that the cause of death was (i) cranial injury; (ii) blunt force trauma; and finally (iii) vehicular collision through the deceased being an unrestrained driver, ejected from her vehicle. The Sheriff noted that the evidence led at the injury indicated that had the deceased been strapped into the vehicle, she would not have left the vehicle, and would likely not have sustained her fatal injuries.

The Sheriff thus made a public declaration outlining the importance of securing seat belts in vehicles each time they are used, to prevent fatal injuries in the event of an accident.

Fatal Accident Inquiry into the death of Mr Bernard Graham [2010] FAI 44

Thu, 04 Nov 2010 22:15:00 GMT

In terms of section 6(1) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the Sheriff made a determination that Mr Bernard Graham died between about 11 pm on 9 November 2009 and 8:25 am on 10 November 2009, within Cell 8, Glenesk Hallm HMP Saughton, Edinburgh.

Having reviewed the extensive investigations into Mr Graham’s death, the Sheriff concluded that he died of natural causes, his right coronary artery (which was affected by severe atherosclerosis) being completely occluded by a haemorrhagic thrombus.

Accordingly, under sub-sections 6(1)(c) and (d), the Sheriff pronounced that there were no reasonable precautions whereby his death might have been avoided, nor there any defects in any system of working which contributed to the death.

Inquiry into the circumstances of the death of Mr Thomas James Strain [2010] FAI 43

Fri, 08 Oct 2010 21:01:39 GMT

The Sheriff found in terms of section 6(1) of the Fatal Accidents and Sudden Death Inquiry (Scotland) Act 1976, that Mr Thomas James Strain died between 13:00 and about 16:30 hours on 23 November 2008 at HMP Bowhouse, Kilmarnock. The Sheriff determined that the cause of death was hanging.
Having heard evidence and submissions, the Sheriff noted that there were no reasonable precautions whereby the deceased’s death might have been avoided, nor where there are any system defects which contributed to the deceased’s death.

Mr. Strain was a 46 year old man serving a 22 month sentence of imprisonment. He was found hanged in his cell at HMP Bowhouse, Kilmarnock, a facility managed privately by SERCO.
The Sheriff noted that a psychiatric report produced at sentencing diet was not available to prison staff during Mr Strain’s initial reception to Bowhouse. The report was also unavailable during subsequent risk assessment processes and case conferences during Mr Strain’s imprisonment.

In the weeks prior to Mr Strain’s death, the Sheriff noted that he had been informed that he would not be released early under the Home Detention Curfew scheme. He was additionally experiencing negative press coverage in the tabloid press, which had not been received well by fellow inmates, resulting in taunting and harassment. On the date of death, the Sheriff noted that Mr Strain had been due to have a visit from his mother, but that prior to this visit, his body had been found suspended by a belt within the toilet area of his cell. Prior to this discovery, Mr Strain’s cellmate had been asleep, and there had been no indications of Mr Strain’s endeavours to take his own life.

Having heard technical evidence about the design of the toilet door in the cell concerned, the Sheriff noted that even if it were altered, a number of suspension points would still exist, and while it would be harder to secure a knotted ligature, it would not prevent the pursuit of someone who was determined to take his own life.

The Sheriff further noted that it was clear the psychiatric report had not been brought to the attention of prison staff. Noting that the absence of the psychiatric report was not material to the outcome in the case, the Sheriff noted that in other cases it would be vital to properly assess the risk of self harm of suicide of other inmates, and therefore, immediate access to any existing psychiatric reports was required upon prison reception. The Sheriff opined that there was merit in introducing a standardized practice whereby court staff would contact prison staff in advance, to alert them that an incoming prisoner would be accompanied by a copy of their psychiatric report.

The Sheriff noted that although the Inquiry had highlighted communication and procedural failings, it was not possible to say that any of these failings played a role in Mr Strain’s death, there being no evidence of any redesign of the cell door which would have made it likely Mr Strain was diverting from the course he ultimately took. Equally, there was no evidence of any warning signs that Mr Strain was contemplating taking his own life, his decision being impulsive. There were no reasonable precautions by which this might have been avoided.

Fatal Accident Inquiry into the circumstances of the death of Mr Francis Goodwin [2010] FAI 42

Sun, 03 Oct 2010 14:45:44 GMT

Fatal Accident Inquiry:- Having heard evidence and submissions, the Sheriff made a determination under the terms of the Fatal Accidents and Sudden Death Inquiry (Scotland) Act 1976, which contained no recommendations. The Sheriff found that in terms of section 6(1)(a) of the 1976 Act, that Mr Francis Goodwin, died at 0500 on 27 July 2005 at Western Infirmary, Glasgow, as a result of road traffic accident, which occurred at around 0420 on the same date. The cause of death was a chest injury sustained as a result of the road traffic accident, and this accident was caused by the careless driving of Mr Sean Crangle.

The Sheriff noted that three vehicles were involved in the road traffic accident: the Royal Mail van driven by the deceased, an ambulance driven by Mr Sean Crangle, and a tanker.

At the time of the accident, Mr Crangle was responding to an emergency response call, and was driving with blue lights flashing, but no siren. At red traffic lights, Mr Crangle proceeded through a junction, and saw a tanker coming from his right. Despite believing this to be the only vehicle on the road, he subsequently saw the lights of a Royal Mail van being driven by the deceased on the far side of the tanker. The ambulance hit the Royal Mail van, causing it to hit the kerb of the central reservation. This impact knocked the Royal Mail van towards the tanker, and hit the tanker twice on the driver’s side, before bouncing off again, and coming to rest against the kerb. During this period, eyewitnesses could see the deceased being violently thrown about inside his vehicle. Following the accident, Mr Crangle was subsequently charged with a contravention of section 3 of the Road Traffic Act 1988 (careless driving) and pled guilty to that charge as amended.

The Sheriff heard evidence on the use of seatbelts by the Royal Mail, and was satisfied that the outcome of the accident would not have been any different had the deceased been wearing a seatbelt. Furthermore, the Sheriff heard evidence about the driving training available to Mr Crangle as an ambulance driver, coming to the conclusion that further training would not have influenced the outcome of the accident. The Sheriff found it was clear that Mr Crangle did not follow the applicable guidance on driving through red lights, and had proceeded to enter a junction where, because of restricted visibility and the speed of his approach, he had no chance of stopping when he realized that the junction was not safe to cross.

The Sheriff concluded that there was no evidence to suggest a different training system or a different instruction about either red lights or warning signs would have prevented this accident.

Fatal Accident Inquiry into the circumstances of the death of Michael Dodds

Thu, 10 Sep 2009 13:53:54 GMT

In his written determination following a Fatal Accident Inquiry into the death of a man in an Intensive Psychiatric Care Unit, the Sheriff set out the purpose of the inquiry, as well as its limitations. He explained that its primary purpose is to air in public the circumstances of the death in order to explain its cause or causes. It also allows an inquiry into, first, whether any reasonable steps could or should have been taken whereby the death would or could have been avoided, and, secondly, whether there were any defects in any system of working which contributed to the death. He stated, however, that the limitations of the inquiry should also be noted: the purpose is to find facts, not to find fault. In many cases, the latter is achieved through later litigation where the normal rules apply of advance notice in writing of each party's case and control of the manner evidence is presented to the court. The Sheriff commented that it is not uncommon for a deceased's family to be disappointed that blame has not been apportioned by the sheriff in his determination and, although this is perhaps understandable, it is often due to a misunderstanding of the true purposes of the inquiry.The Sheriff went on to say that a common problem with fatal accident inquiries is that one or more of the interested parties is anxious to leave no stone unturned to ensure that every possible circumstance surrounding the death is aired in evidence. Sometimes that is warranted; sometimes it is not. The Sheriff expressed gratitude to the parties involved in the inquiry for the manner in which they represented their various interests.

Mrs Ivy Niven for Judicial Review of a Decision of the Lord Advocate dated 8th May 2008 [2009] CSOH 110

Thu, 30 Jul 2009 15:24:29 GMT

In this petition for judicial review the petitioner sought to challenge the decision of the Lord Advocate, dated 8 May 2008, refusing a request that a fatal accident inquiry be held into the circumstances surrounding the death of the petitioner's daughter. On 19 December 1995 Richard Karling was found guilty of the murder of the petitioner's daughter on 27 June 1995. He subsequently lodged an appeal against his conviction and at the appeal hearing further evidence was led. A key aspect of the Crown case against the appellant was the presence of temazepam in the deceased's system which was subsequently shown not to be present. During that appeal hearing at the High Court in Edinburgh in June 2000, the Crown withdrew its opposition and Mr Karling's conviction was subsequently overturned and he was consequently released from custody. Here the petitioner sought declarator that she was entitled to an independent, effective and reasonably prompt public inquiry into the death of her daughter at which her next of kin could be legally represented and be provided with the relevant material and be able to cross-examine the principal witnesses. It was submitted that the failure on the part of the respondent to provide such an inquiry was incompatible with article 2 of the European Convention on Human Rights, and ultra vires of section 57(2) of the Scotland Act 1998. The petitioner also sought declarator that the decision of 8 May 2008 to refuse to order a fatal accident inquiry under section 1(1)(b) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 and a public inquiry in terms of section 1 of the Inquiries Act 2005 was unreasonable and irrational. Further, the petitioner sought declarator that the Lord Advocate was obliged to order a fatal accident inquiry under either the 1976 or the 2005 Act within such period as the court may determine. Here the court considered the investigations which have occurred into the circumstances of Ms Niven's death to date and whether they can properly be described as effective and what further investigations may be appropriate having regard to what, if any, new information concerning the circumstances of the death have been obtained by any party. The central issue for the court here was whether article 2 obliged the respondent to order a further inquiry into Ms Niven's death.

Roseleen Kennedy & Jean Black v. The Lord Advocate and the Scottish Ministers & the Lord Advocate & Scottish Ministers [2009] CSOH 1

Thu, 08 Jan 2009 17:40:00 GMT

On 5 February 2008 an Opinion was issued and the Court pronounced interlocutors in the two petitions, which reduced the decision of the first respondent in refusing to order a Fatal Accident Inquiry into the deaths of Mrs. Eileen O'Hara and the Reverend David Charles Black. At that time the court ordered that a further hearing be arranged in each petition for the discussion of further procedure. After 5 February 2008, the Court was advised that the respondents did not intend to reclaim against the interlocutors. On 23 April 2008 the Cabinet Secretary for Health and Wellbeing, Nicola Sturgeon MSP, made a statement to the Scottish Parliament on behalf of the Scottish Government in which she announced that a judicially-led public inquiry under section 28 of the Inquiries Act 2005 would be held. Here the petitioners sought declarator on a number of matters connected to that public inquiry including declarator that "an inquiry which was to be held under and in terms of Section 28 of the Inquiries Act 2005 alone would not, in fact, be compatible with the requirements of providing an effective remedy for the established breaches of the petitioners' Article 2 rights". In addition the petitioners sought an order on the first respondent to hold Fatal Accident Inquiries under the Fatal Accidents and Sudden Deaths Inquiries (Scotland) Act 1976, and an order on the second respondents to waive the financial conditions of eligibility for legal aid which might otherwise apply to the next of kin. At a late stage during the continued first hearings of the petitions, the petitioners tendered a minute of amendment in each petition, which sought inter alia to convene the Advocate General as an additional respondent to the petitions. Counsel for the respondents opposed the motions to allow the minutes of amendment to be received and intimated to the Advocate General. Here the Court considered whether the Advocate General should be convened as a party to the proceedings at such a late stage in addition to the various matters contained within the petitions.

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

Kotke v Saffarini [2005] EWCA Civ 221 (09 March 2005)

Wed, 09 Mar 2005 00:00:00 GMT

The claimant’s claim for loss of dependency under s. 1(3)(b) of the Fatal Accident Act 1976 failed, where the Court found, on the evidence, that the claimant had not been living with the deceased, in the same household, for 2 years before his death. There needs to be at least 2 years’ continuous co-habitation to maintain a claim under s. 1(3)(b). A mere intention to live together, general sharing of shopping expenses or discontinuous co-habitation will not suffice.