Source · Scotland · Fatal Accident Inquiry
Peter Carter
Scotland — FAI
Custody
4 recommendations
Reference ALO-B40-23
Published 1 January 2024
Determination
| Reference | ALO-B40-23 |
| Published | 1 January 2024 |
| Sheriff | Sheriff Neil Bowie |
| Sheriffdom | Tayside Central and Fife |
| Date of death | 11 June 2019 |
| Location | Forth Valley Royal Hospital (prisoner at HMP Glenochil) |
| Cause of death | Post-surgical complications; blood test oversight failures |
Recommendations 4
NHS Forth Valley
NHS Forth Valley to review clinical oversight of blood test results within laboratories; establish parameters for increased clinical oversight; system for flagging abnormal results; review discharge process for patients returning to prison
No mandatory response mechanism — unlike PFD reports (England & Wales), recipients are not required to respond.
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About FAIs
Fatal Accident Inquiries are held under the
2016 Act
before a sheriff. They are mandatory for deaths in custody and at work.
The sheriff may make recommendations under s.26(1)(b) but there is no enforcement mechanism.