Education May Notalways Satisfy, Whatcan Be Said Is That There Is Same Happening to Anyone Else’

education may notalways satisfy, whatcan be said is that there is same happening to anyone else’. into circumstances ofadeathby seekingto ‘avoid the FAIs provide a robust a means of undertaking examination • 2Rightto life: Article under theEuropean Convention onHumanRights deaths whereby theStatecomplieswithitsobligations transparent and public mechanism for inquiring into criminal, may also follow. Inconcluding, FAIs provide a death. Other procedures, and civil or disciplinary type ofprocedureone specific thatmay result from a the determination issued by thesheriff. FAIs are only role of FAIs including consideration of the significance of FAIbe held, will theprocedure, types, locationandthe FAIs. 2discusses the legislationgoverning Part whena 1 outlines thehistorical backgroundPart and context of and elsewhere. interest toothermedicalpractitioners bothinScotland investigations into deaths/FAIs. Itshouldalsobeof no experience of Scottish procedures relating to Scotland who have qualified in other jurisdictions with a death. It is directed primarily at doctors practising in communications withdeceased relatives following such may enhance how medical practitionersdeal with medical profession’s role insuchinquirieswhich, inturn, promote a greater understanding of such FAIs and the FAIs by reference to these medical-type FAIs. It aims to This paper considers generally thenature and role of the medicaltreatment and care inrelation tothedeath. annually will focus on the role of of the actual delivery For the medical profession, a few of the FAIs instructed investigation of deaths occurring inScotland is involved. FAIs provide where mechanism thelegal judicial Fatal (FAIs)Accident Inquiries are uniquetoScotland. Introduction in Scotland their role inrelation to the medicalprofession Fatal Accident Inquiries: raising awareness of 254 at COPFS. member oftheLayCommitteeRoyal CollegeofPhysiciansEdinburghandwas aProcuratorFiscal Depute workingintheDeathsUnit Gillian Mawdsley isaScottish practising solicitor and iscurrentlyalawtutoratEdinburgh,Strathclyde and GlasgowUniversities. Sheisa G Mawdsley Perspective provided by law. conviction of a crime for which this penaltyis the execution following his ofasentencecourt one shall be deprived of his life intentionally save in Everyone’s right to life shall be protected by law. No Although their outcome . Accident Inquiry One such helpful document is unions thatdetailedadvicecanandshouldbeobtained. from the legal profession and the medical defence This paper does not seek to provide legal advice. It is from what has happened. providedan opportunity for allinvolved tolearnlessons Part 1: Context and Background ofFAIs to publish thedetermination. The determinationisthe sheriff presiding over theFAI whoseresponsibility itis (involved inproviding opinionevidence) andthe expert appearing before theFAI), fellow medicalprofessionals conducting the FAI and representing the parties the relatives), the legal profession (responsible for FAIs may also involve membersof the public(including their everyday professional life. unwelcome (and potentially concerning) interruption to will doubtless arrivewitness at a sheriff court as an death that results in a FAI, the citation to appear as a have beenclinically involved inthecircumstances of a of hindsight, underdetailedscrutiny. For doctors who processes, where suchissues are now, withthebenefit medical examination, diagnosis and decision-making will be providing substantial evidence about their and non-contentiousnature. Somedoctors, however, where evidence provided will be of a relatively routine medical procedures, such as admission and blood tests, merely doctors will Certain bespeakingonroutine be citedforwill court. are likely to have been involved at different stages and instructed inrelation toaspecificdeath, various doctors reasons,require will apost-mortem. When aFAI is a medicalpractitioner. A number ofdeaths, for various death must be followed ofthedeath by by certification familiar withtherole ofgivingevidence atFAIs. Any those involved in Accident andEmergency, be very will appear ataFAI. Somedoctors, suchas pathologists and Many doctors who practise medicine inScotland never Context 1

255 3 es, Types, Much of the of Much 4 Fatal Accident Accident Fatal Inquiries Once such a death is Once such a death is 5 I a FA ole of [The 2016 Act] will strengthen Fatal Accident Inquiry Fatal Act] will strengthen [The 2016 ensuring legislation and bring it into the 21st century, fair… efficient and effective, inquiries are that There being no coroner in Scotland it is the duty of in Scotland it is the duty being no coroner There fiscal] in cases PF [procurator his the Sheriff and individual suspect that any to reason is there where other any from violence or met his death by has the body to have immediately natural causes, a precognition take to medical men and examined by the case.of the circumstances regarding reported, an investigation will be conducted by the willby be conducted investigation an reported, 8 March on unit launched their specialist by now COPFS, Unit, Fatalities Investigation Scottish the as known 2011, 2016 Act has still to come into force. come still to Act has 2016 Procedure A death death. be a must there be held, can a FAI Before ‘reportable been a will have FAI culminates in a that local the to reported be must that one namely death’; wide, are the categories where Fiscal Procurator suicide, deaths arising from example, for including, suspiciousor due to violent, drowning, accident, abortionto attempted or related unexplained causes, unknown. remains the cause abortionwhere and occur being discussed, to the FAIs The deaths relevant a where death any and mishap medical a of result a as which suggests that medical complaint is received have may or the absence of treatment treatment contributed to the death. which provides expertise all for specialist advice and which provides fiscals. procurator on, Procedure, Procedure, ion, Legislat 2: Part and R ion Locat Legislation being held inquiries currently governing The procedure Deaths Sudden and Accidents Fatal the by governed is now is Act that Recognising 1976. Act Inquiry (Scotland) and Safety Community the Minister for old, 40 years the forward brought Wheelhouse, Paul Affairs, Legal Deaths etc. Accident and Sudden Inquiries into Fatal Act 2016 indicating that: (Scotland) of a number Act adopt in the 2016 included The changes the Cullen in Lord by made recommendations the Accident Inquiry of Fatal Report of Review of findings 2009. in November published Legislation quoted by Robertquoted by in The opposition S Shields of lawyers to 179). inquiries accident of fatal 2014 SLT the introduction Accidents Fatal the with enacted first was Legislation 1895 that set out the procurator Act Inquiry (Scotland) investigation with the in dealing responsibilities fiscal’s his from came role His inquiries. such of initiation and criminality: exclude and prosecute to duty public interest Criminal and civil justice 2 9 254– 46: 2016; J R Coll Physicians Edinb Coll Physicians J R © 2016 RCPE require certification as to the cause of death, be it in certificationof death, to the cause as require or in civil be detected to to permit murders criminal law estate. deceased’s the of administration the allow to law make systems legal Scottish and the English Both accidental, suspicious, sudden, into investigations death any as well as unexplained deaths unexpected and an efficient The operation of to them. that is reported of system is the legal responsibility death investigation Coroner the Inquest and and the COPFS in Scotland Wales. and in England system procedures administrative in Scotland, Historically, in fiscal investigated, the procurator existed where ‘was That all accidental or industrial deaths. private, ‘the to [the English system]’ with preferable thought of repetition endless the and the exposure, vulgarities, 266-267 Rev. inquest’ ((1893) 5 Jur. the Coroner’s Background of course, of is, death that of cause the Investigating public interest The kin. of next the to interest immediate wider. in deaths is much formal finding issued at the conclusion of the FAI setting FAI the of conclusion the at issued finding formal of cause and place time, the about information core out though the agreed, details are these Mostly death. contributing a as infection, hospital- borne a inclusion of resisted. been previously have well may factor to a death, recommendations, can seek to make The determination if the of the death on the circumstances if relevant, the civil on (based the evidence sheriff is satisfied with probabilities). the balance of namely proof, of standard with the case. be familiar will already the doctor If cited, arisen in a complex to have is likely death The sudden memorable). and be both distressing case (and therefore The review. in a critical case featured already have It may the police by been precognosed have well may doctor Office and withina member of staff the Crown and/or Fiscal Service Procurator the facts, to (COPFS) as the death. to in relation their role and background in court, and before both doctors, for process The FAI place inevitably, inquiries, and such can be stressful not is It spotlight. the under professionals medical should not be held when the that a FAI suggested However, be avoided. should merit it or circumstances in educating role a have does the medical profession and being familiar with types of the FAIs itself about to subject or mishap medical from arising deaths the of relatives The FAI. in a result might that complaint not to be heard, a FAI for request a will make deceased but FAI a of purpose the appreciating fully necessarily (and poor communications perceived on based the from with medical professionals understanding) the importance the initial of stresses That outset. information of the disclosure with and communication death. after immediately relatives the deceased’s to education were website. published on the Scottish Courts 2015 toSeptember2016, only 25FAI determinations seem anunusually highnumber ofFAIs. From September deaths per yearbe thesubjectofaFAI. will That does Procurator Fiscal. Itstates, onaverage, about 50–60 over 11,000 deaths in Scotland are reported to the perspective, according toScottishGovernment statistics, To put the number of FAIs being held annually into G Mawdsley families of a deceased person’. to ‘the emotional trauma [that holding a FAI] caused to the death. Sheriffconcern has been expressed in relation even if there appear to be no lessons to be learnt from The COPFShas nodiscretion as to holding an inquiry FAIcomprise a mandatory induecourse. who died while under police detentioninKirkcaldy will included under this category. The death of Sheku Bayoh Suicides, as well as prisoners dying of natural causes, are • or under: Pan American airline, the plane, sincetheaircrew were employees ofthe inquiry, despite the obvious criminal act in bringing down The Lockerbie FAI wasanexampleofamandatory • inquiriesare heldeitherunder: Mandatory on the circumstances of the death. FAIs depending ordiscretionary canbeeithermandatory Types holding FAIs. totheethos and public interestsomewhat in contrary As will beseen from later discussion, that perhaps runs website does indicate that: Determinations are normally allpublishedalthough the • inquiriesareDiscretionary heldunder: 256 will the details will bepublished. a significantpointoflawinterest public orparticular not all judgments are published. Only where there is at the timeof his death, inlegalcustody the person who has Section 1(1)(a)(ii) died was, person, was engaged in hisoccupation as such. employment or, beinganemployer orself-employed died, beinganemployee, wasinthecourseofhis occurringthe personwhohas inScotlandwhile that thedeathhasresulted from anaccident of the1976 (a) (i) Section 1(1) Act where itappears circumstances of thedeath on theground that it under this an inquiry Act should be held into the Advocate to beexpedientinthepublicinterest that whereSection 1(1)(b) itappears to theLord 8

needed flexibilityover location. 2016 Act (inforce September2016)provides much changed were previously piecemeal. Section12of the local court. Arrangements enablingFAI venues tobe creates delay in holding FAIs if they must be held in the Pressure schedulingandspace today, onthecourts’ public (including relatives and press who were attending). accommodate andensure appropriate facilitiesfor the of the number of witnesses being heard and to Royal Hospital, Dumfries. That wasnodoubtonaccount example, theLockerbiewasheldatCrichton inquiry holding inquiriesbecausethey canbeimpractical; for maySheriff courts notalways present thebestvenue for more expedienttoholdtheFAI inFort William. such asthelocationofwitnessesorrelatives, itmightbe medical treatment at Fort William, for practical purposes issues focused ontheclimbingaspectsand/orinitial probably beheldinGlasgow SheriffCourt. However, ifthe Hospital, Glasgow. The patientdied. The FAI would treatment followed attheQueen Elizabeth University Medical treatment was administered locally. Specialist Consider ifthere wasaclimbingaccidentonBenNevis. as itsounds. death occurred. That isnotnecessarily as straightforward with the closest connection to where sheriff court the location oftheFAI. Traditionally, allFAIs were heldatthe A doctorwhoiscitedtoaFAI may wonder atthe Location subject ofa long runninginquestinLondon. where the death of Princess Diana in Paris was the deaths arising inScotland. This isincontrast to England now beincluded. Previously, FAIs could only beheldinto (section 2ofthe2016 Act). DeathsofScots abroad will and deaths under police arrest regardless of location include deaths It willofchildren insecure accommodation FAIin whichamandatory mustbe widened. beheldwill continue under the 2016 Act though the range of deaths Note thatthedistinctionbetween thetypesofFAIs isto are assessed is discussed under the role of the FAI. public concernfor aFAI tobeheld. How thesefactors expedient, in the public interest or gives rise to serious does not meantheLord Advocateconsider it is will category.discretionary Just because the death is reported FAIsbe instructedunderthis intomedicaldeaths will following questions, some clarityisobtained. should beheldintoamedical death?Byposingthe What doespublicinterest meanwhenconsidering ifaFAI R ole of the FAI serious public concern. occurred incircumstances such astogive riseto was sudden, suspicious or unexplained, or has J R Coll Physicians Edinb 2016; 46 : 254–9 © 2016 RCPE education 257 The case of Fatal Accident Accident Fatal Inquiries 12

He died the following week. All All week. He died the following 11 the business of killing people. Sometimes things go Sometimes things go the business of killing people. by staffed institutions are hospitals wrong…because competent trained and well however beings, human the made, are mistakes such If be. may staff the civil in a sued be may responsible persons, or person, however occurrences, such But litigation. When the Lord Advocate makes a decision not to hold makes Advocate When the Lord the family. be verydecision can that for upsetting FAI, a understanding unrealistic an on be based to tend may That can and is about FAI what the of expectation and of comments a number made Sheriffs have achieve. of medical FAIs: the role about particularof a The interests does not necessarily family Sheriff Principal Sir coincide with the public interest Bt QC in the Inquiry into the Young Stephen ST at of Mrs Eileen Peterson of the death circumstances to balance the the need 2006) stressed Lerwick (10 July the medical and the family between interests various under were whose actions professionals Medical staff. for caring and working continue to needed scrutiny ‘the strain inevitably This subjected them to patients. evidence give to having of prospect with the associated of any being made the subject perhaps and at a [FAI] the end…’ public criticism at Medical deaths must be viewed in context be viewed Medical deaths must the by judicial review an unsuccessful Emms involved to refusal Advocate’s the Lord of mother deceased’s ‘possible’ been had claimed that there She had FAI. a hold which had caused employees hospital by systemic failure his death. contributed to or a complicated medical history. son had Her 49-year-old he was admitted to hospital and in hospital, On arrival gastrostomy endoscopic A percutaneous artificially. fed was inserted. Trust the internal the pathologist, by investigations and the independent consultant gastroenterologist, review with the care problem been no had there that concluded clinical decision making or the to the patient, provided The insertion. gastrostomy endoscopic percutaneous further that nothing would considered Advocate Lord FAI. a in holding be achieved not in: are Doctors The families’ concerns are inevitably motivated by them them by motivated inevitably are families’ concerns The FAI The occurred. death the why to as answers wanting in a mineshaft in non-medical death Hume’s Alison into a determination in a FAI that effects 2008 illustrates the her rescue delayed rules had safety Health and can have. ‘accelerating’ held as factors which were six hours, for including line rescue measures, safety New her death. Minister, Safety Community in place. now are training, FAI that following indicated Cunningham, Roseanna from learned be, to will continue and been, have ‘lessons event’. the tragic

10 9 254– 46: 2016; 9 J R Coll Physicians Edinb Coll Physicians J R © 2016 RCPE What are the families’ views? families’ the What are will be a FAI on the holding of The families’ views to the not paramount the COPFS but are by considered of the Lord decision which is made at the discretion Advocate [2011] 29 Emms v Lord [paragraph Advocate CSIH 7]. of the investigation had the outcome Families will have including the experts’ them, explained to into the death of issues worthy any addressing specifically opinion, COPFS has The FAI. a of exploring in the context in its procedures about useful information provided Access Relatives: Charter Bereaved to Charter: Family Fiscal in Liaison with the Procurator and Information to Act. the 2016 8 of section of the implementation Are issues of patient safety involved? of patient issues Are the in safety is to promote The primaryof a FAI purpose deaths inquiries into public having by public interest are They 849]. S.L.T. 2007 Petitioner Advocate, [Lord the public as ‘expense neutral’, as described therefore fiscal the procurator by incurred costs the purse bears consideration a be to cost Were the public. in representing that few to suppose might venture one in holding a FAI, In 1991, interest. in the public be instructed ever would £3m. cost and Inquirydays 61 for Lockerbie ran the the will require issues medical involving FAIs Inevitably, expertof number a of attendance reports. and witnesses or short not cheap in duration, are they Consequently, evidence. medical the of nature and complexity the given involved Weir of Sharman death into the the FAI Indeed, field and expertUK six pre-eclampsia in the consultants 43 days. for ran Families need to understand the role of a FAI. At the a FAI. of the role understand Families need to written a a later date, at usually conclusion, FAI’s The sheriff. the by issued be must determination 6(1) of the of which is set out under section framework that state the sheriff must FAI, in every Act where, 1976 his to been established have circumstances the following any and when the death and as to (a) where satisfaction (b) the place and took in the death resulting accident resulting accident any and death such of causes or cause findings’). ‘formal as to referred (sometimes death in the further is if he findings make to on go sheriff may The 6(1) under section presented on the evidence satisfied reasonable (c) were Act that there the 1976 of accident any and the death whereby if any, precautions, (d) been avoided, in the death might have resulting contributed which working of system any in if any, defects, in the death and accident resulting to the death or any to the circumstances relevant other facts which are (e) any ‘discretionary as to the death (sometimes referred of findings). such not make findings’ since the sheriff may all FAIs of third one only suggested it is Anecdotally, discretionary in such being made. findings result education adversarial. Representation suchas the family for parties )).(sui generis They are inquisitorial innature and not proceedings (described as being in a class of their own be left unturned There is a perceptionby the families is that no stoneshould been avoided. circumstances whereby MrGreig’s death might have a matterfor theFAI, whichwasconcerned only with advancement of medicaleducation. However, itwasnot Hospital and the death might be significant in the link between an admission at the Royal Alexandra treatment formed the basis of the inquiry. Making the Alexandra Hospital, Paisley, six days previously whose was not linked to his earlier presentation at the Royal Hospital (where hisdeath was recorded). That death deceased’s wife. The patient had died at the Vale of Leven The deathwasonly investigated attheinstigationof under paragraphs (c), (d)or (e). thrombosis.artery findingswere Nodiscretionary made due toacutemyocardial infarction duetocoronary and (b) that the cause of death was haemopericardium Hospital, Gordon Greig…died at the Vale of Leven G Mawdsley death. finding the facts that contributed or caused of the confirmed thatthescope of aFAI isanexercise in acts, ofanorganisation oromissions FAIS are intoprocedures, notageneral inquiry irregularities, not made, otherdeaths might follow. personal negligence but, crucially, where changes were interest inFAIs iswider, aimedatsystemicfailures or forum butofitsown, does not justifyaFAI. The public may well arise. That potentialactionliesinadifferent of each case, possibleallegations of medical negligence not conjecture. In considering the facts and circumstances must befounded on the basis of relevant evidence and by thefamily justifyingthepublicinterest inholdingaFAI regard cannot be over-stressed. Any concerns expressed The independence of the COPFS’ investigation in this and to beprovided withaccess tothemedicalrecords. died, tobeinformed of the conclusionof any investigations The family hasarighttoknow why theirrelative has 258 deaths in thefuture. (Emms(paragraph [27]pp453) deficiencies are notaddressed, there may bemore deaths attributable to themor, that ifthese deficient that there may have beena number of and procedures in operation at the hospital were so of such a nature that gives concern that the system example of error of judgment, or carelessness, but is indicative of not just a one-off situation, or a single has apparently gone quite seriously wrong, whichis raise questions of publicconcernunlesssomething relatives ofthepersons who dieas a result, do not understandably distressing they may be to the 13 determinationstated(a)thatThe sheriff’s Alexandria, on 2 March 2007at 20:45 hours FAIs are neithercriminalnor civil SheriffDJLeslie (11 August 2009), (11 August circumstances of the death of Michael Dodds at Dundee Sheriff Derek CWPyle, into the at theinquiry v Scott Lithgowknown (Black 1990 S.L.T. 612 at pp 615). blame There isnopower inaFAItoapportion The concerns spoken may or may not be warranted. toheartheremaindertheir placeincourt oftheinquiry. allow themtosetouttheirconcerns. They canthentake deceased’s relativesbe thefirstwitnessatFAI will to interested inaFAI isoptional. Inany event, the would engender and promote their more efficientuse. for all concerned in theprocess/procedure of FAIs if thedeath could have beenavoided. Betterawareness the relatives. FAIs explore the facts at issue in determining intoa death nor offer panaceas to encompassing inquiry FAIs have distinct roles; they are not designed to be an ‘that blamehas not been apportioned’. the court’. The deceased’s family may well bedisappointed case and control ofthe mannerevidence ispresented to rules applyof eachparty’s ofadvance noticeinwriting ‘[Later] litigation [can be pursued] where the normal Their purposefacts.was nottofindfaultbutelicit none have beenimplemented. recommendations issued by a sheriff after an FAI, or why organisations explain how they have implementedany follow uprequirements toensure that individuals or 2016 Act comes into force, there are no monitoring or sheriff are notlegally binding. Untilsection28of the see, but any recommendations currently made by the The determinationshouldbepublicly available for allto Sharman Weir,supra). Reith: intothecircumstances ofthedeath Inquiry any recurrence ofsuchadeathinthefuture’. (Sheriff Inquiry, [that]may bepersuaded totake steps to prevent and the Determination of the evidence led at the Inquiry FAIs ‘are armed withthebenefitofhindsight, the seen as a quite separate and distinct process. A FAInot willprevent such proceedings but should be incriminate, or negligence action. resulting indisciplinary Doctors may fear thatevidence given ataFAI could from an inquest; for instance, or verdict. there is no jury the publicinterest. FAIs are quitedifferent inprocedure FAIs are independent of all interested and held in parties isnotexemptprivate healthservice from suchinquiries. be dominated by public sector and the NHS, though the death involved inaFAI are open-ended. MedicalFAIs will potentially, any medicaldeathcould, asthecategories of FAIs. Noteveryresult medicaldeath will inaFAI; Doctors should beaware oftherole ofmedical-type Conclusion 14 recognised that FAIs had limitations. J R Coll Physicians Edinb 2016; 46 : 254–9 © 2016 RCPE This iswell 15 education

259 Fatal Accident Accident Fatal Inquiries https://www.scotcourts.gov. The Family Liaison Charter: Charter to Bereaved Relatives: Charter Charter: Liaison Relatives: to Bereaved The Family Access to Information and Liaison with the Procurator Fiscal. http:// Fiscal. and Liaison with the Procurator to Information Access www.copfs.gov.uk/images/Documents/Deaths/COPFS%20 Family%20Liaison%20Charter%20September%202016.pdf 24/11/16). (accessed says Scots ‘lessons learned’ Alison Hume mineshaft death BBC News. http://www.bbc.co.uk/news/ 24 October 2012. . government 14/9/2016). (accessed uk-scotland-glasgow-west-20073760 Inquirydeath of Mrsof the circumstances into the Peterson. Eileen Paragraph 9. https://www.scotcourts.gov.uk/search-judgments/ 9. Paragraph (accessed judgment?id=da3d87a6-8980-69d2-b500-ff0000d74aa7 24/11/16). https://www. InquiryConclusion. Greig. death of George into the scotcourts.gov.uk/search-judgments/judgment?id=fd9686a6-8980- 24/11/16). (accessed 69d2-b500-ff0000d74aa7 Inquiry into the circumstances of the death of Michael Dodds. https:// www.scotcourts.gov.uk/search-judgments/ (accessed judgment?id=933087a6-8980-69d2-b500-ff0000d74aa7 24/11/16). Inquiry into the death of Norma Haq. uk/search-judgments/judgment?id=4c5386a6-8980-69d2-b500- 24/11/16). (accessed ff0000d74aa7 What must be remembered at all times is that the death at all times is be remembered What must and Sympathy someone. to bereavement a was of the of the nature irrespective the loss, for condolence while of the FAI at the forefront remain must death, in inquiring into the issues interest meeting the public death. that surrounding COPFS. 10 COPFS. 11 12 13 14 15 http://www.scotcourts.gov.uk/search- 9 254– 46: 2016; . April InquiryAccident . 2014 Essential Guide to the Fatal . http://www.copfs.gov.uk/ deaths. in investigating Our role 2008. Section 6(ii)(b). http:// 6(ii)(b). Section 2008. Fiscal. Procurator and the Death http://www.mddus.com/media/1681/fai_bookletjun14.pdf http://www.mddus.com/media/1681/fai_bookletjun14.pdf 15/9/2016). (accessed & Clinical Medicine Forensic W. Smock, A, Busuttil J, Payne-Jones 2003. Ltd; Media Medical Greenwich London: Aspects. Pathological p.13–26. Edinburgh: 7th edn. Dictionary. of the Law of Scotland and Digest Bell’s 2012. Trust; Legal Education Edinburgh Accident Inquiry Legislation. of Fatal Review Scottish Government. http://www.gov.scot/Publications/2009/11/02113726/0 2009. 16/9/2016). (accessed judgments/fatal-accident-inquiries (accessed 16/9/2016). (accessed judgments/fatal-accident-inquiries Journal of the Law Society of Scotland policy. Sheriff questions FAI 23 September 2008 http://www.journalonline.co.uk/ 24/11/16). (accessed News/1005733.aspx#.V-Vd0_ArK00 Weir. InquirySharman of of the death circumstances into the https://www.scotcourts.gov.uk/search-judgments/ (accessed judgment?id=13c286a6-8980-69d2-b500-ff0000d74aa7 1/12/16). www.copfs.gov.uk/images/Documents/Prosecution_Policy_ Guidance/Guidelines_and_Policy/Death%20and%20the%20PF.pdf 24/11/16). (accessed (accessed investigating-deaths/our-role-in-investigating-deaths 24/11/16). Accident Fatal Inquiries. J R Coll Physicians Edinb Coll Physicians J R © 2016 RCPE References 1 MDDUS. 2 3 4 5 COPFS. There is naturally considerable public interest in FAIs; in FAIs; public considerable interest is naturally There With the Bin Lorrycase. Glasgow the example, for this will in future, recommendations of monitoring if see to audit an with public scrutiny enable more required. if implemented, been have recommendations give to learn and opportunities will More be provided mechanism. the FAI learnt through to lessons effect 8 9 COPFS. 6 COPFS. 7