The Fatal Accident Inquiry and the role of the Procurator Fiscal is a process unique to Scotland. Dr Rachel Birch, MPS medicolegal adviser, outlines a case and provides guidance.
Care concerns
Mrs S was an 84-year-old who had been resident in a nursing home for the past two years. She had a history of recurrent falls, vertigo, hypertension and ischaemic heart disease. If she took her time, she was usually able to move about the nursing home with the aid of a Zimmer frame. However, she got up quickly from her chair one Saturday evening to go to the bathroom. Unfortunately she became dizzy and fell and immediately complained of pain in her hip and knee. She was given paracetamol and helped into bed.
The following day she continued to complain of pain and was unable to get herself out of bed. She needed two members of staff to transfer her to the bathroom.
The nursing home staff called Dr H on the Monday afternoon and requested a visit. Mrs S had remained in bed and was now chesty. Dr H felt that clinically Mrs S had a chest infection and a hip fracture and arranged hospital admission by ambulance.
At admission Mrs S was found to have a fractured neck of femur. A chest x-ray revealed left lower lobe pneumonia but also the presence of two healed rib fractures on the right side. Mrs S was treated with antibiotics with the aim of surgery once her chest was improved. However, she deteriorated over the next two days and died.
What happened next?
The family expressed concern about the care that she had received from the nursing home. They felt that the nursing staff should have contacted the family and the OOH doctor on the Saturday evening. They met with the consultant responsible for Mrs S’s care and told him that they felt that a delay in seeking medical help for her hip fracture had contributed to her death.
They were also upset to learn that Mrs S had been found to have old healed rib fractures and were concerned that recurrent falls in the home had caused this. They told the consultant that they had previously raised concerns about two of the carers with the nursing manager for the home, but that little appeared to have changed since then.
The consultant reported the death to the Procurator Fiscal (PF), since the death had occurred following a fall. He told the PF that the family had expressed concerns about the nursing home care, both recently and in the past. The family were concerned that other patients may potentially be at risk at the home. The consultant also discussed the family’s concerns with the Care Inspectorate, the body responsible for regulating nursing home care.
The PF decided to investigate the death further. As part of this investigation, Dr H was asked for a statement. As well as reviewing and admitting the patient, Dr H was the doctor responsible for conducting regular Friday morning visits to the nursing home. The PF requested a background summary of the patient’s health over the last few months, details of previous falls and a statement regarding the final visit.
The PF also asked Dr H to comment on the concerns raised about the nursing home, and whether he had previously been aware of any shortcomings in care. Dr H called MPS for advice as he had never had to provide a written statement to the PF before. MPS assisted him with his statement and advised him that he was providing a statement as a witness to fact. It did not appear that there would be any criticism of the care he had provided, and he had been unaware of any criticism of the nursing home in the past.
The Care Inspectorate carried out an investigation of the nursing home and made recommendations regarding deficiencies in communication and the training of new staff. A new falls policy was adopted within the home and the Care Inspectorate arranged to review the matter again later in the year.
As a result of the Care Inspectorate’s involvement, the PF felt it was no longer necessary to proceed with Fatal Accident Inquiry (FAI), as the potential public interest concern was being addressed.
What doctors should do if the Procurator Fiscal requires a statement
The Procurator Fiscal (PF) may request a witness statement from GPs or other health professionals to investigate a death and decide whetherto proceed with a fatal accident inquiry (FAI).
The GMC states that doctors should disclose relevant information about a patient who has died to help a PF with a Fatal Accident Inquiry.1 Not all cases proceed to an FAI. However, doctors must be prepared to give evidence at a potential FAI and should consider this when drafting their statement.
The procurator Fiscal: A recap
One of the duties of the PF is to undertake inquiries into sudden or unusual deaths. This role is similar to that of the coroner in the remainder of the UK. There are 11 PFs each covering a specific geographical location. In total, PFs investigate around 14,000 sudden deaths each year.
There are some deaths that must be reported to the PF. These include:
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potentially violent or unnatural deaths (including accidents or suicide)
- sudden deaths of unknown cause
- deaths in prison or police custody
- deaths as a result of an industrial or infectious disease that may pose a serious risk to public health.
Doctors should also report deaths if there were contributory medical causes, including any complications or deficiencies in care. If a death is the subject of a complaint you should also discuss this with the PF. This list is not exhaustive and if you are unsure about whether or not to report a death, you should contact the PF, who will be able to advise you further. The Crown Office and Procurator Fiscal Services have produced useful guidance for doctors in this regard.2
In addition to doctors, police officers and the Registrar of Births, Deaths and Marriages may also report a death to the PF. If a death is sudden the Procurator Fiscal will often ask the police to interview medical and nursing staff and family members to produce a report to assist them in collating the relevant information.
Deaths may sometimes be reported because no-one has been able to issue a death certificate. The PF must decide whether a postmortem is necessary to establish the cause of death. In most cases reported to the PF, early inquiry can rule out suspicious circumstances and establish that the death was due to natural causes.
However, the PF has a duty to inquire into deaths that occur due to violence, unnatural circumstances, in custody or sudden deaths with unknown cause. The PF will decide whether there is a need for a criminal prosecution, or if a Fatal Accident Inquiry should be held, under the Fatal Accident
and Sudden Deaths Inquiry (Scotland) Act 1976.3
Fatal accident inquiries
The PF investigates many more cases of sudden death than actually result in FAIs. FAIs take place with nothing like the frequency of coroners’ inquests in the remainder of the UK. There are around 50 to 60 FAIs held each year. An FAI must be held when a death was caused during employment, or while in legal custody, ie, while being held at a police station or prison.
In other circumstances, an FAI may be held where there are issues of public safety or matters of general public concern arising from a death, and there is a need to highlight or investigate dangerous circumstances or systems that have caused or contributed to it.
The views of the deceased’s relatives are also taken into account when deciding whether to conduct an FAI. The PF makes an application for an FAI to the sheriff whose sheriffdom appears to be most clearly connected with the circumstances of the death. If an FAI is held, this is independent to any other criminal or civil proceedings.
Any individuals whom the PF believes may be able to provide relevant information will be asked to give evidence. GPs will be asked for statements if they were involved in the deceased’s care prior to death. They are often also asked for a background medical statement, even if the death occurred in hospital, since they will have access to the full GP medical records and are likely to have known the patient best.
FAIs are held by the sheriff in court. They may take several days, depending on the complexity of the case. At the end of an FAI, the sheriff makes a determination. The determination will set out where and when the death occurred and the cause of death. The sheriff may also, if he or she thinks it appropriate, comment on any precautions by which the death might have been avoided and any defects in systems that caused or contributed to the death. However, an FAI cannot make any findings of fault or blame against individuals.
References
- General Medical Council, Confidentiality (2009)
- Death and the Procurator Fiscal: Information and Guidance for Medical Practitioners (October 2008)
- Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act (1976)