Source · Scotland · Fatal Accident Inquiry

Sophia Evangeline Smith

Scotland — FAI Health 2 recommendations Reference [2025] FAI 41 Published 15 October 2025

Determination

Reference[2025] FAI 41
Published15 October 2025
SheriffSheriff Joanna McDonald
SheriffdomGlasgow and Strathkelvin
Date of death11 April 2017
LocationRoyal Hospital for Children Glasgow
Cause of deathPVL-MSSA infection

Recommendations 2

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Addressed to: NHSGGC Public Health Scotland
Recommendation 1: Weekly screening of vulnerable neonates in intensive care is a useful early warning of Staphylococcus aureus colonisation. This can inform clinical decisions with regard to possible infection and antibiotic therapy. NHSGGC should review the existing protocol in order to ensure that it is properly complied with at all times. Other Health Boards should consider adopting a similar screening process. Recommendation 2: Public Health Scotland should disseminate information on; (a) the risks associated with PVL-MSSA; (b) the difficulties of diagnosis; (c) the advantages of early antibiotic and anti-toxin therapy, and; (d) the learning described by Dr Jonathan Coutts in his evidence, to other neonatal clinical teams throughout Scotland.
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.

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