Reports > The Third Report > CHAPTER EIGHTEEN - Systems of Death Investigation and Certification in Other Jurisdictions >
The System in Scotland
|
18.124 |
Ms Elizabeth Anne Paton, Procurator Fiscal Principal Depute, Crown Office and Procurator Fiscal Service, Edinburgh, attended the seminar and described the system in Scotland. |
Background and Structure
|
|
18.125 |
The Crown Office and Procurator Fiscal Service (COPFS) is a Department within the Scottish Executive, headed by the Lord Advocate, assisted by the Solicitor-General, and is responsible for independent public prosecution and deaths investigation in Scotland. The COPFS headquarters are based at the Crown Office, in Edinburgh. The Procurator Fiscal Service is divided into 11 areas and the boundaries conform as closely as possible to the boundaries of the Scottish police forces. Those 11 areas are divided further into a total of 49 districts. In larger districts, the district procurator fiscal is assisted by a procurator fiscal depute. Both are legally qualified. The Lord Advocate and Solicitor-General are assisted by Crown counsel, who are senior members of the Scottish legal profession, seconded to the Department for a period of about three years. Crown counsel prosecute in the High Court and review and advise on individual cases dealt with by the procurator fiscal. |
|
18.126 |
In Edinburgh, the Crown Office has a deaths department, with a Procurator Fiscal and a Procurator Fiscal Depute (Ms Paton), who are assisted by a part-time member of the legal staff, an administrator and a secretary. Approximately 2000 deaths are reported in the Edinburgh district each year and autopsies are carried out on approximately half that number. Although the Procurator Fiscal directs investigations, s/he does so with police assistance, particularly in the undertaking of preliminary enquiries, which enables the Procurator Fiscal to take decisions as to the future conduct of an investigation. The Edinburgh police force has a dedicated team of inquiry officers. However, outside Edinburgh, preliminary investigations are undertaken by all police officers. |
Statutory Framework
|
|
18.127 |
The Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 defines the statutory duties of the procurator fiscal in respect of the investigation of deaths. The Registration of Births, Deaths and Marriages (Scotland) Act 1965 provides a statutory framework for the registration of deaths. |
Objectives
|
|
18.128 |
The Scottish system bears many similarities to the system in England and Wales. However, it focuses on the holding of a public inquiry in a case giving rise to serious public concern. |
Deaths Not Reported to the Procurator Fiscal
|
|
18.129 |
Only certain categories of death are reported to the procurator fiscal. In those cases where the death is not reported, the deceased's treating doctor certifies the cause of the death. The certification procedure for those deaths is similar to the procedure in place in England and Wales, in that a doctor who has treated the deceased during his/her last illness is under an obligation to issue an MCCD. One significant difference in the Regulations is that, under the Scottish system, there is no provision making reportable to the procurator fiscal a death where the certifying doctor has not seen the deceased within a specified period. There is no requirement on the doctor to examine a body after death in order to certify the cause of death; however, Ms Paton said that good practice dictates that this should be done. |
Deaths Reported to the Procurator Fiscal
|
|
18.130 |
A large number of specific categories of death are reported to the procurator fiscal for investigation, including any uncertified death. The procurator fiscal also retains a broad discretion to examine any death where it is in the public interest for him/her to do so. Deaths are generally reported by general practitioners, hospital doctors and the police, and, to a lesser extent, registrars of deaths, where reportable deaths have progressed to the stage of registration. Occasionally, reports are received from members of the public. A telephone call from a person reporting a death will often be put through directly to the procurator fiscal; otherwise, in the first instance, the call will be taken by an administrator or secretary. Details of the report of death are noted on a specifically designed form, recording administrative details as well as the history. Only a member of the legal staff is authorised to advise a doctor to certify the cause of death. The procurator fiscal may ask the police to verify certain factual matters before allowing a doctor to certify. |
Death Investigation
|
|
18.131 |
In cases where a death is to be investigated, the procurator fiscal will typically instruct the police to carry out preliminary enquiries. In some areas, dedicated police officers (or 'inquiry officers') are available to carry out investigations on behalf of the procurator fiscal. The police will then submit a report, containing the deceased's personal details, information as to the circumstances of death and the medical history. The procurator fiscal will then determine what further investigative steps should be taken. The precise investigative steps will, of course, depend on the circumstances of the individual case. If there is no certificate of cause of death, the next step is likely to be an autopsy. In most parts of Scotland, however, the procurator fiscal would have the opportunity of a 'view and grant' as an alternative to an autopsy. The Inquiry has received evidence on the 'view and grant' procedure, which derives its name from the fact that a pathologist will view the external aspects of the body, and if s/he can confidently provide a cause of death, grant an MCCD. When carrying out the examination, the pathologist will have available to him/her the police report and the deceased's medical records. |
|
18.132 |
Further witness statements might be taken by the procurator fiscal or a member of the legal staff. Potential witnesses might be called in for interview to the procurator fiscal's office, a process known as precognition. The procurator fiscal might also meet the families of the deceased. Medical advice might be sought from a pathologist in the first instance and, in a case where the death is associated with medical care, an independent expert with appropriate expertise will be instructed to review the case and prepare a report. As in England and Wales, the investigation is directed by a lawyer, not a doctor. |
|
18.133 |
In Edinburgh, autopsy services are provided under a block contract with the Department of Forensic Medicine at the University of Edinburgh. Two full-time forensic pathologists carry out the autopsies and are also available to provide medical advice when the need arises. This is the only medical expertise immediately available to the procurator fiscal. The decision to order an autopsy is made by the procurator fiscal and, although there is no formal right on the part of the family to object to the carrying out of an autopsy, in practice any objections made will be taken into account during the decision-making process. The procurator fiscal will request histology or toxicology in an appropriate case and, where the need arises, the pathologist will approach the procurator fiscal and request permission to carry out further investigation. If there is a suspicion of criminal involvement, the autopsy will be carried out by two pathologists. If not, a single-doctor autopsy will be ordered. Following an autopsy, the pathologist prepares a report, which is significantly more comprehensive and detailed than the equivalent report produced following a coroner's autopsy in England and Wales. |
|
18.134 |
In the Edinburgh district, the practice is to carry out full autopsies in every case. The 'view and grant' system is not available in Edinburgh. One further noteworthy exception to the full autopsy in Scotland was the practice adopted following the murder of a number of children at a school in Dunblane in 1996. They were shot by a gunman who went on to take his own life. In those circumstances, and on the basis that there could be no subsequent criminal proceedings, the murderer having taken his own life, x-ray examinations of the bodies were taken, in place of autopsies. |
|
18.135 |
The procurator fiscal is under an obligation to report certain categories of death to the Crown Office, for Crown counsel to decide as to the future conduct of the case and as to whether it is necessary for a prosecution to be brought or a fatal accident inquiry to be held. If the case does not fall into one of those categories, at the conclusion of the investigation the procurator fiscal will make an order that there be 'no further proceedings'. |
|
18.136 |
When a death is first reported to the procurator fiscal, a provisional cause of death will be provided where possible and the registrar informed of the provisional cause. At the conclusion of the procurator fiscal's investigations, the registrar will either be told that the provisional cause of death is confirmed or be informed of the amended cause. Personal attendance for the purposes of registration is required in Scotland, as in England and Wales. |
Judicial Investigation of Death
|
|
18.137 |
The closest equivalent in Scotland to the inquest that is held in England and Wales is the fatal accident inquiry. There is only a relatively small number of fatal accident inquiries and, in the year 2001-2002, only 64 were held, out of a total of 13,625 deaths reported to the procurator fiscal. Fatal accident inquiries are chaired by a sheriff, who is a legally qualified judge, and the case is presented by a procurator fiscal. Fatal accident inquiries are held in public. |
|
18.138 |
Fatal accident inquiries are mandatory in the case of a death caused by an accident in the course of employment or in the case of a death in legal custody. Fatal accident inquiries are also held at the Lord Advocate's discretion, which is guided by a number of principles, including whether the death occurred in circumstances such as to give rise to serious public concern. In the case of a discretionary inquiry, the views of the bereaved family as to the holding of an inquiry are taken into account. Where a death is apparently caused by a system failure, it is more likely that an inquiry will be held than if it appears to have been caused by an individual failure. The purpose of the inquiry is to establish where and when a death took place, the cause of the death and, in general terms, the cause of any accident that resulted in the death. Findings will be made about any reasonable precautions that might have prevented the death. Following a fatal accident inquiry, it is open to the sheriff to make recommendations for the purposes of future public safety. The recommendations are forwarded to the relevant body or organisation by the procurator fiscal. Although the recommendations do not have legal status, they apply political pressure to implement changes in furtherance of public safety. |
|
18.139 |
Where there is no fatal accident inquiry, no formal report or document is prepared summarising the investigation carried out by the procurator fiscal. However, the procurator fiscal will hold discussions with the family and, where the family is interested in receiving further information, details of the investigation and the evidence obtained can be provided. In addition, the autopsy report will be made available to the family. Where appropriate, the report can be sent to a general practitioner in order for the medical aspects of the report to be explained. Alternatively, the family will be invited to a meeting with the procurator fiscal and a pathologist, who will explain the medical aspects of the report. |
Detecting Shipman
|
|
18.140 |
On the basis of summaries describing the circumstances of four of Shipman's unlawful killings, Ms Paton formed the view that Shipman's activities would probably not have been detected by the procurator fiscal system, as it is implemented in Edinburgh. In relation to the case of Mrs Grundy, she said that 'old age' would have been acceptable as a cause of death because Mrs Grundy was over 80 years of age. Although the death should have been reported to the procurator fiscal, on the basis that it was sudden, the doctor could have certified the cause of death without reporting it. Even if the death had come to the attention of the procurator fiscal, depending on the precise circumstances and discussion with the treating doctor, the procurator fiscal might well have given the treating doctor permission to certify the cause of death. It is possible that the police would have been instructed to undertake a preliminary investigation into the circumstances of death, but neither the procurator fiscal nor any member of his/her staff would necessarily have made any direct enquiries of the family. |
|
18.141 |
In relation to the death of Mrs Ivy Lomas, who was unlawfully killed by Shipman on his surgery premises, Ms Paton said that the list of reportable deaths to the procurator fiscal had been amended in the light of Shipman's crimes to include deaths that occur in a general practitioner's surgery. At the time of the death, however, the death might well not have been brought to the attention of the procurator fiscal and, in any event, as in the case of Mrs Grundy, the investigation would have been unlikely to have uncovered Shipman's unlawful activity. |
Comments
|
|
18.142 |
The system in Scotland is similar in many respects to that in England and Wales. However, the discretion to select for public hearing only those cases which raise issues of serious public concern has the effect of reducing the number of cases in which a public hearing is necessary and of ensuring that hearings are not held in cases where they can serve no useful purpose. |
|
18.143 |
I was also interested to hear about the involvement of families in the decision as to whether or not a public hearing should take place and, in the event that no such hearing is thought appropriate, of the arrangements made to inform the family about the deceased's death and its cause. |
|
The System in Finland
