The Scottish Government

17/12/07

Death caused by an accident during the course of employment

John Brown

02/06/07

Death caused by suicide at HM Prison, Perth

1) In circumstances where the reaction of a patrolling officer called to a cell may depend on the number of prisoners in that cell, she or he ought to have immediate access to information about that matter.

2) If a prisoner has previously been placed on ACT (Assessment, Context, Care and Treatment, a procedure whose purpose is to assess a prisoner's behaviour and attitudes with a view to identifying risks), that fact should be 'flagged' clearly in the prisoner's records, in such a way that it will definitely be seen by anyone making a subsequent assessment.

Clark James Isard

Tayside, Central and Fife

30/05/07

Death caused by suicide at HM Prison, Perth

1) Consideration should be given to ensuring a copy of the policy custody form accompanies a prisoner to prison.

2) Consideration should be given into a method for passing information from one agency to another about whether a prisoner has been seen by a medical professional while in police custody, the reason for such a visit, and any medication given.

10/03/07

Death caused by electrocution during the course of employment

24/11/06

Death caused by traumatic asphyxia during course of employment.

1) While the tipper of the vehicle was raised the tailgate could have been securely closed by fastening the turnbuckles at either side of it and also the slip rings on the verticle arms at either end of the locking bar; and

2) Mr Bisset could have refrained from standing within the intake, or indeed anywhere else, behind in or in the immediate vicinity of the tailgate of the vehicle while the tipper was raised.

21/10/06

Death due to Meningococcal sepsis

20/10/06

Road traffic accident during the course of employment

28/08/06

Death caused by an accident whilst operation a fun-fair ride.

18/07/06

Death caused by suicide at Barlinnie Prison

17/07/06

Death caused by an accident when fishing

a) recommends that consideration be given by those responsible for the warning signs on the bank of the river adjacent to the Holiday Park as to whether it would be appropriate to include a sign warning users of the banks of the river adjacent to the Holiday Park of the dangers posed by the artificial fluctuation in the rate of flow of the river caused by the Operations of the Power Station

b) it is appropriate to make a recommendation that consideration may be given to the wording of the signs so that clearer warning can be given without the specific dangers created aritificially by the extensive use of Power Stations. That might be done by a sign prohibiting fishing as well as swimming because of the dangers of the fluctuating river flow, or by drawing attention to the liklihood of a change in the rate of flow caused by the power station.

28/6/2006

Suicide in HM Porterfield prison

It was submitted that a reasonable precaution whereby Mr Auckland's death might have been avoided would have been for if the door of Mr Ackland's cell had been opened fully when he unlocked it rather than unlocking it but merely leaving it closed. The suggestion was that, if Mr Ackland had only just hanged himself, he might have been found in time to be resuscitated.

Jim O'Neill
Communications Manager
Scottish Prison Service
Room 338
Calton House
5 Redheughs Rigg
EH12 9HW

Tel: 0131 244 8476

E-mail:gaolinfo@sps.gov.uk

17/06/06

Death in Peterhead Prison caused by Renal Failure, Hypertension, Ischaemic Heart Disease and Perpheral Vascular Disease

14/06/06 -15/06/06

Death in HM Prison Noranside

4/06/06-5/06/06

Suicide in Barlinnie Prison

18/05/06

Death caused by road traffic accident

16/05/06

Death caused by a road traffic accident during the course of employment.

10/05/05

Death caused by an accident during the course of employment.

08/05/06

Death caused by a road traffic accident

1) That the accident and resulting deaths might have been avoided had Aberdeenshire Council, as Roads Authority, taken the reasonable precaution of causing advanced signage to be erected on the Pole of Itlaw to Mill of Brydock Road to better alert drivers heading westwards to the presence of a junction with the A97;

2) That the accident and resulting deaths might have been avoided had Aberdeenshire Council, as Roads Authority, taken the reasonable precaution of ensuring that the road markings at the junction of the Pole of Itlaw to Mill of Brydock Road were properly maintained and readily visible to the drivers of vehicles using that road;

3) That at the time of the accident Aberdeenshire Council, as Roads Authority, failed to have in place within the Banff and Buchan Area an up to date, reliable, robust and effective system for the inspection and repair of road markings;

Road Safety & Traffic Management Team
Ist Floor St Nicholas House
Broad Street
Aberdeen
AB10 1EZ

28/04/06

Death in Peterhead Prison caused by Intracerebral Haemorrage, Hypertensive and Ischaemic Heart Disease

21/04/06

Accident during course of employment

08/04/06

Overdose during weekend release from HM Prison, Castle Huntly

02/04/06

Death as a result of Meningococcal Septicaemia

a) The provision of a 'routing tool' sufficient to enable a Call Handler to initiate immediate emergency action in respect of the presentation of symptoms of meninococcal septicaemia.

George Crooks
Medical Director
NHS 24
Delta House
50 West Nile Street
Glasgow
G1 2NP

Tel: 0141 225 0099
E-mail:george.crooks@nhs24.scot.nhs.uk

29/3/06

Death caused by road traffic accident

20/03/06

Death in prison caused by Coronary Artery Disease

15/02/06

Suicide in Perth prison

04/12/05- 06/12/05

Suicide after attendance at Vale of Leven Hospital

25/11/05

Suicide in Barlinnie Prison

19/11/05

Sudden Death in Wishaw General hospital

That a system should be brought into place so that each patient attending should be given a copy of the plaster instructions and a records of that should be kept.

Shona Welton
NHS Lanakshire
Head of Patient Affairs
Divisional Headquarters
Strathclyde Hospital
Airbles Road
Motherewell
ML1 3BW

Tel 01698 245002

E-mail:shona.welton@lanarkshire.scot.nhs.uk

William Kelly

Grampian, Highlands and Islands at Peterhead

1 day

11/11/05

Death in custody in hospital of natural causes

None

27/10/05

Death in prison caused by diabetic ketoacidosis

26/10/05

Death in Prison caused by drug overdose

11/10/05

Blunt force trauma caused by road traffic accident

Alan Wilson

15/09/05

Tractor accident in course of employment

None

15/09/05

Suicide in Barlinnie Prison

25/08/05

Road traffic accident during course of employment

Robert Watson

24/08/05

Death in hospital following tractor accident in course of employment

None

23/08/05

Compressive injury to the neck and chest following an accident during the course of employment

22/08/05

Death inflicted by a serving prisioner at Castle Huntly

Consideration should be given at Castle Huntly to the system of assessment of suitability of a prisoner for short release with the view to effectively assessing the risk to the community and to putting in place measures to to minimise any potential risk.

Jim O'Neill
Communications Manager
Scottish Prison Service
Room 338
Calton House
5 Redheughs Rigg
EH12 9HW

Tel: 0131 244 8476

E-mail:gaolinfo@sps.gov.uk

10/08/05

Head Injury caused by accident during course of employment

03/08/05

Death caused by road accident

Glasgow and Strathkelvin at Glasgow

25/07/05

Sudden death due to epilepsy in custody in Barlinnie Prison

22/07/05

Suicide in HM Prison, Perth

George Watson

Tayside Central and Fife at Dundee

14/07/05

Road accident in course of employment

07/07/05

Head and chest injuries due to crushing by wall

1) The system of exemptions and exceptions to building standards legislation might with advantage be re-drafted in language which is clearer.

2) Guidance should be issued for persons who might be affected by the relevant building standards regulations.

Gary Fraser

17/06/05

Suicide in Barlinnie prison

Grampian Highlands and Islands at Peterhead

10/06/05

Suicide in Peterhead Prison

Michael Lyle

2 days

08/06/05

Suicide in Barlinnie prison

08/06/05

Death in hospital caused by a fall

a) A reasonable precaution whereby the death might have been avoided was the undertaking of a CT scan in the early hours of 07 June 2005 following her vomiting at 1.50 am.

b) In the event that that opportunity was missed a further reasonable precaution whereby the death might have been avoided was the undertaking of a CT scan after Mrs Heffernan had vomited around 5.00 am.

Shona Welton
Head of Patient Affairs
Divisional Headquarters
Strathclyde Hospital
Airbles Road
Motherwell
ML1 3BW

Tel: 01698 245002

E-mail:shona.welton@ lanarkshire.scot.nhs.uk

Scott Whyte

7/06/05

Road traffic accident

5 days

17/05/05

Suicide in Polmont Young Offenders Institution

Jamie Forsyth

South Strathclyde, Dumfries & Galloway

29/04/05

Death from drug abuse in police custody

Donald MacRae

14/04/05

Road traffic accident in the course of employment

05/4/05

Death caused by a railway accident during the course of employment

01/04/05

Road traffic accident in the course of employment

Tayside Central and Fife at Perth

1 day

14/03/05

Crushing head injury caused by accident

The Health and Safety Executive should advise other firms in the building and joinery trades who are involved in installing doors that they should take precautions to store doors flat along their long edge battened together and should advise workers to handle them in that position except when during fitting. A further precaution would be to provide some information about the weight of the doors as this might prevent more than one door being held at one time.

Health and Safety Executive
Belford House
59 Belford Road
Edinburgh
EH4 3UE
Tel: 0131 247 2000

09/03/05

Death in a Care Home caused by pneumonia.

01/03/05

Death in Ayr Hospital caused by meningococcal septicamia and bilateral adrenal infraction

Ranjit Singh

Lothian and Borders at Edinburgh

28/02/05

Multiple internal injuries to the head, chest and spine caused by accidental fall at work

None

Margaret Graham

Grampian, Highland and Islands at Inverness

17/02/05

Death in hospital

(1) There should not in future be shared consultant clinics whereby a middle grade doctor does not have direct access to the consultant in charge of the patient's care.

(2) There should be closer liaison between middle grade doctors treating a patient and the consultant responsible for care.

(3) Notes of patients attending the Asthma Clinic should be previewed by the consultant wherever possible.

(4) There should be closer liaison between primary and secondary care, preferably by telephone, should a patient under hospital management develop an apparent intercurrent illness in the community.

(5) There should be proper access to online laboratory results in all the outpatient consulting rooms at Raigmore Hospital.

Dr Alison Graham
Board Medical Director
John Dewar Building
Highlander Way
Inverness
IV2 7GE

Tel 01463 706929

E-mail:alison.graham@haht.scot.nhs.uk

17/02/05

Suicide in Perth prison

None

01/02/05

Death in police custody

Lothian NHS board and Lothian and Borders Police to consider how details of diagnosis and treatment are returned with the patient to the relevant police station.

Dr Charles Swainson
Medical Director
NHS Lothian
Deaconess House
148 Pleasance
Edinburgh
EH 8 9RS

Tel 0131 536 9135

E-mail: charles.swainson@lhb.scot.nhs.uk

Ian Dickinson,
Acting Deputy Chief Constable
Lothian and Borders Police
Fettes Avenue
Edinburgh
EH4 1RB
Tel: 0131 311 3131

2 days

18/01/05

Death in custody in hospital

16/01/05

Sudden death in hospital

Darran Allan

11/01/05

Road traffic accident in the course of employment

Derek Crook

Tayside, Central and Fife

22/12/04

Suicide in Castle Huntly Prison

Grampian Highlands and Islands at Stornoway

19/12/04

Death at sea in the course of employment

All fishermen would benefit by the development of suitable personal floatation devices which can be worn at all times when working on board any fishing boat without hindrance to the wearer. These devices should be approved and regulations put in place to make their use compulsory.

A very high profile warning should be included in the advice to all crew members of all sea-going vessels about the inadvisability of going to sea when under the influence of alcohol. This should emphasise the very considerable danger of there still being too high a blood-alcohol level in the bloodstream the morning after a heavy drinking session. Such amplified advice should always be included in any safety course and in any reminders or refreshers which may take place in training courses.

Fishing and Code Vessel Safety Branch bay 2/05
Spring Place
105 Commercial Road
Southampton
SO15 1EG

E-mail:fishing@ mcga.gov.uk

Tel - 023 8032 9524

Robert Robertson

Glasgow and Strathkelvin

1 day

12/12/04

Suicide in Barlinnie prison

None

Ronald Bell

Tayside Central and Fife at Perth

01/12/04

Crushing injuries sustained as a result of being trapped under the hydraulic boom of a Manitou load handler

Agricar Ltd should specify in their safety manual that on no account should anyone work under a raised hydraulic boom without the said boom being supported by a prop or some other item providing sufficient support.

Agricar Ltd
Registered Office: 6 Lochside Road, Forfar, DD8 3JE,

Directors: J.D.Milne, J.Johnston

19/11/04

Multiple injuries and blunt force trauma following a vehicular collision

None

Robert McKellar

North Strathclyde

16/11/04

Head and neck injuries caused by a fall at work

None

16/11/04

Suicide in Shotts Prison

All of the past records of a prisoner should be obtained by the establishment in which they confined where there is a history of self-harm and particularly in circumstances where they have at any time been a patient at the State Hospital, Carstairs

The parents of a young prisoner about to start a significant sentence should be interviewed to ascertain a full history especially where the prisoner has a history of self-harm

A case manager must be appointed when a prisoner is admitted to the segregation unit at Shotts Prison

Staff should be trained in the criteria to be used when a prisoner is to be transferred from the National Induction Centre.

A period of notice of at least two or three days should be given to a prisoner before they are transferred from the NIC.

Jim O'Neill
Scottish Prison Service
Communications branch

Telephone : 0131 244 8476

E-mail:gaolingo@sps.gov.uk

Dennis Topen

1 day

14/11/04

Multiple injuries sustained as a result of blunt force trauma suffered as a result of a road accident

The following improvements should be carried out:

(a) A combined strategy be developed for the B934 and B9141 junctions with the A9 restricting the vehicles using the B934 junction to those requiring to avoid the low bridge on the B9141

(b) New half mile advance junction warning signs be installed on the A9 in relation to the B934 and B9141 junctions with the A9

(c) Vehicle activated 'Vehicles emerging from junction' and '70 miles per hour slow down' signs be installed on the A9 to the north of the junction with the B934

(d) The traffic signs on the B934 be improved with larger 'give way', dual carriageway ahead', 'road layout' warning signs being installed on the B934 on the approach to the junction with the A9.

Consideration should be given to a speed camera being positioned by the southbound carriageway of the A9 on the approach to the junction with the B934 together with the appropriate road traffic sign warning of the presence of said camera in order that the speed of vehicles in said carriageway be regulated.

Consideration should be given to the possible reduction of the speed limit in the vicinity of the junction of the A9 with the B934.

Consideration should be given to the installation of street lighting at the junction of the A9 and the B934.

Steps be taken to raise the awareness of the terms of the Road Traffic Lighting Regulations insofar as these provisions relate to the illumination of the sides of trailers

Works carried out by the Scottish Executive Trunk Roads Department at a cost of circa £250,000:

· Buff coloured anti skid surfacing on both carriageways

· New road markings

· New (more visible) road signs at this junction and at the adjacent Dunning Junction

· Vehicle activated signs on both junction approaches to indicate "70 mph slow down" when vehicles exceed the speed limit.

· Vehicle activated sign on southbound approach which indicates "Turning Traffic Ahead". This is triggered by the presence of a vehicle in the side road or in the central reserve.

The junction continues to be monitored in view of the measures undertaken. In addition, studies are continuing into the medium/long term strategy regarding the A9 between Perth and Stirling with a view to possible Junction improvements.

Department of Transport
Great Minster House
76 Marsham Street
London
SW1P 4DR

Fax: 020 7944 9643

road.safety@dft.gsi.gov.uk

02/11/04

Suicide at Cluny Clays by Kircaldy

1. Consideration should be given to the creation of an Information Sharing Agreement between the police and shooting establishments like Cluny Clay's, under which information about revocations and refusals could automatically be passed.

2. That Firearm Licensing Departments should be obliged to notify GPs when their patients become certificate holders, and GPs should in turn be obliged to notify Firearm Licensing Departments should they become aware of any mental illness suffered by such patient. This could be achieved by the consent of the applicant on an application form, or by the introduction of an Information Sharing Agreement between an individual police force and the respective GPs.

3. That all shooting establishments ask the specific question in all cases 'have you ever had a shotgun certificate refused or revoked?', before issuing a shotgun to visitors.

4. That shooting establishments introduce a similar 'Referee' system as introduced by Cluny Clay's after the death of Mr Murray. Further, visitors to shooting establishments should, in all cases, be asked to prove their identity by producing a passport, driving certificate or similar along with their address and a record should be kept once this has been done.

5. That there should be a specific statutory prohibition against persons whose certificate has been revoked having possession of a shot gun under any circumstances.

6. That it should also be made an offence for any person knowingly to give a shot gun any person whose certificate has been revoked.

7. That the statutory application form be amended so as to include express permission for the fact of the application itself, and of any subsequent grant, refusal or revocation of a certificate to be disclosed to any person having a legitimate interest to receive such information including without prejudice to that generality (a) the applicants GP and (b) any shooting establishment within the UK.

8. That the police carry out a check to ensure an applicant has no medical problems before granting or renewing a certificate.

9. That the layout at Cluny Clays be changed so that the car park cannot be reached other than by passing a permanently staffed reception, to make it impossible for an individual to return to the car park directly from the shooting area.

Firearms Control
5th floor
50 Queen Anne's Gate
London
SW1H 9AT
Tel: 020 7035 4848

Scottish Executive
Police Powers and Duties Etc
1st Floor West Rear
St Andrew's House
Regent Road
Edinburgh
EH1 3DG
0131 244 2367

Scottish Executive
Confidentiality of Health Records and Freedom of Information
Basement Rear
St Andrew's House
Regent Road
Edinburgh
EH1 3DG
Tel: 0131 244 2345

Association of Chief Police Officers Scotland (Secretariat)
173 Pitt Street
Glasgow
G2 4JS
Tel: 0141 532 2057

Shomi Moshina

Steven Wiseman

Grampian, Highlands and Islands at Aberdeen

26/10/04

21/12/04

Death in Aberdeen Royal Infirmary

1. Consideration should be given to devising a formal system to ensure as far can reasonably be done, that algorithm outcomes are not overridden save for clear identified reasons.

2. That the ability of nurse advisors to make that decision should be tested before they are allowed to do so, and should thereafter be regulary reviewed.

3. The occasions where the outcomes are overridden should be recorded together with the reason and overrides should be monitored regularly.

4. In cases where a 999 hospital admisssion or an urgent consultation with a doctor is concerned consideration should be given as to whether the concurrence of a supervisor should be obtained before such an outcome is overridden.

George Crooks
Medical Director
NHS 24
Delta House
50 West Nile Street
Glasgow
G1 2NP

Tel: 0141 225 0099
E-mail:george.crooks@nhs24.scot.nhs.uk

DCr Roelf Dijkhuizen
Medical Director
NHS Grampian
Foresterhill House
Ashgrove Road West
Aberdeen
AB25 2ZB

Tel: 01224 553 714
E-mail:Roelf.dijkhuizen@arh.grampian.scot.nhs.uk

22/10/04

Death caused by an aricraft accident during the course of employment

Andrew McIntosh

Grampian, Highlands and Islands at Aberdeen

18/10/04

Suicide in Aberdeen prison

None

13/10/04

Suicide at Cornton Vale Prison

Rodger Devlin

South Strathclyde Dumfries and Galloway at Lanark

05/10/04

Severe head injury caused by motor vehicle accident during the course of employment

None

30/09/04

Sudden death in hospital

Thomas Morrison

Lothian and Borders at Haddington

1 day

22/09/04

Multiple injuries caused by a fall at work

Scott Currie

20 days

20/09/04

Suicide in Inverness prison

16/09/04

Death of prisoner in hospital

None

David Wilson

Lothian and Borders at Selkirk

5/09/04

Industrial accident in the course of employment

1. (i) No written procedures existed for the loading of vehicles at Rosyth nor for the basis of rejection of loads if the timber packing was unsuitable.

(ii) The pyramid stacking system of loading on the trailer was unsuitable for a load of this nature.

(iii) There was no written procedure for the safe unloading of vehicles at the point of delivery and for the safe accommodation of the driver at the point of delivery.

(iv) There was no system in place to enable the driver of the vehicle to know the loading or unloading system at any yard to which deliveries were made.

(v) There was no familiarity with any safety policy and an over-reliance on experience on the job.

2. (i) No written procedures for the safe unloading of vehicles at St. Boswells were in place.

(ii) There was no system in place to enable Colin Robertson Timber to know whether those driving delivery vehicles were aware of the unloading system.

(iii) There was no familiarity with any safety policy and no system in place to make certain that the vehicle drivers were in a safe place before the commencement of unloading of vehicles.

James Moffat & Sons (Cardenden) Ltd
Fulmar Way
Donibristle Industrial Park
Dalgety Bay
KY11 9YY

Colin Robertson Timber
Charlesfield
St Boswells
Melrose
Roxburghshire
TD6 0HH

Alexander Martin

30/08/04

Natural death in Castle Huntly Longforgan prison

None

Andrew Buchanan

Perth

23/08/04

Blunt force trauma sustained in a road traffic accident

William Stewart

Glasgow and Strathkelvin

21/08/04

Suicide in custody in Glasgow Sheriff Court

(1) The frequency of observations of prisoners in cellular custody in Glasgow Sheriff Court should be formalised and committed to writing, both in respect of ordinary prisoners and special risk prisoners.

(2) A system requires to be introduced to record in writing either on a form at a cell door or/and in a prisoners PER (prisoner escort record) when observations have taken place.

(3) Having taken the advice of the Health and Safety executive, Reliance Custodial Services require to clarify their Operating Instructions as to what steps their employees are required to take for suicide risk prisoners in respect of removal of belts and braces, ties and scarves, boots or shoe laces, string/ cord in jackets and any article which may be perceived to be a risk.

(4) Reliance Operating Instructions thereafter require to be amended in terms of the action taken in respect of recommendations (1), (2) and (3) and these amendments brought to the attention of the staff.HH

Ronnie Beattie
Reliance Custodial Services
Prism House
Rankine Avenue
Scottish Enterprise Technology Centre
East Kilbride
G75 0QF

Tel: 01355-599460

Robert Balmer

Tayside Central and Fife at Perth

14/08/04

Suicide in Perth prison

South Strathclyde, Dumfries and Galloway

3 days

12/08/04

Fall at work

None

Thomas Fergus

Grampian Highland and Islands at Kirkwall

12/08/04

Major pelvic injury caused by fall during self-employed work

None

Glasgow and Strathkelvin

15/08/04

Prisoner died in hospital

None

29/07/04

Head Injury caused by fall in course of employment

None

23/07/04

Suicide at Dungavel Immigration Removal Centre

(1) Persons who are detained by the authorities and who do not speak or have a good understanding of English should have access to an interpreter on any occasion on which (a) they are being interviewed in a context in which either their right to remain in the United Kingdom or their liberty, either short or long term, is in issue and (b) when an important decision about them or their future is being communicated to them. If, in the absence of an interpreter, that communication is in the form of a document, the document should be translated into a language which they can understand. When the physical or mental health of such a person is being assessed by a doctor or nurse there should be interpretation facilities available and they should be used whenever the person being assessed does not have sufficient ability in English to enable a reliable assessment to be made.

(2) Failure to facilitate communication between non-English speaking detainees and the authorities detaining them is likely to lead to wrong assessments being made, wrong decisions being taken, risks to the physical or mental health of such detainees and to injustice to at least some of them. Their inability to speak English should not be permitted to deprive them of information which English speakers would be given nor of the opportunity to provide relevant information and to challenge decisions which may be made about their future. In short, they should not be in a worse position than those who speak and understand English. Persons who are deprived of their liberty without knowing or being able to find out why nor for how long they will be detained are likely to be particularly vulnerable.

(3) Protocols or guidance should be provided to ensure consistency in the availability and use of interpreters and the translation of documents. The difficulties in providing interpreters and translation should not be underestimated, nor should the cost. It is not possible to predict when and where a non-English speaking immigrant or asylum seeker will be detained nor what language that person will be able to speak. In the case of Dungavel, which can accommodate up to 194 people, the numbers of detainees who will require the services of an interpreter at any given time will almost always be very limited or may be nil.

(4) Because of the possible difficulty obtaining the services of a suitable interpreter at short notice, it is recommended that consideration should be given to the preparation of improved questionnaires for use by nurses and doctors when assessing detainees. The following questions were suggested:

1. Have you any worries about your physical or mental health at present?

2. Is there anything to do with your physical or mental health which you would like help with?

3. When did you last see a doctor?

4. What did you see the doctor about?

1. 5. Have you had any medical problems in the past with your:

Eyesight

Hearing

Chest

Heart ... etc

6. Do you take any medication for anything?

7. Are there any medicines which make you ill?

8. Are you allergic to anything?

Questions designed to discover details of any history of mental illness and to assess the risk of self harm would have to be added or interpolated.

Consideration should also be given to translating the questions in such questionnaires into languages likely to be spoken by non-English speaking detainees, and, if they prove useful and successful, into other languages.

(5) It is highly desirable that important decisions relating to detainees, such as removal direction notices should be communicated to them in a language they can understand.

Deputy Director Operations (Detention Service) ,

Immigration and Nationality Directorate
4th floor
Greenpark House
29 Wellesley Road
Croydon
CR0 2AJ

Tel: 020 8760 2212

Grampian, Highland, and Islands at Banff

07/07/04

Car accident in course of employment

Joseph Beattie

North Strathclyde at Dunoon

23/06/04

Multiple injuries due to road traffic accident in course of employment

11/06/04

Death caused by aspiration of gastric contents and acute alcohol intoxication

a) Consideration may need to be given to delivering the information contained in the Servewise course more frequently.

b) It is for Parliament to consider what measures may contribute to social change.

Alcohol Focus Scotland
2nd Floor
166 Buchanan Street
Glasgow
G1 2LW

Tel: 0141 572 6700
Fax: 0141 333 1606
Email: enquiries@alcohol-focus-scotland.org.uk

Public Health and Substance Misuse: Alcohol
Area 3EN
St Andrew's House
Regent Road
Edinburgh
EH1 3DG

Tel: 0131 244 5117

Janet Allen

North Strathclyde at Greenock

9/06/04

Choking on food in hospital

There should be a system for ensuring that patients are provided with the consistency of food necessary for their dietary needs.

The Catering Management and the Speech and Therapy Department of Inverclyde Royal Hospital should liaise over the type of food which is suitable for particular patients' dietary needs.

There should be available at each mealtime a soft consistency food for patients with eating and swallowing difficulties.

Dr Brian Cowan
Medical Director
South Glasgow Acute Hospitals Division
Southern General Hospital
1345 Govan Road
Glasgow
G51 4TF

Tel: 0141 201 1311

E-mail:brian.cowan@sgh.scot.nhs.uk

Elyse Powell

07/06/04

Fall from roof

Brian Gordon

11/05/04

Head injuries sustained in road traffic accident during employment

None

Hamish Wilson

19/04/04

Asphyxia and crush injury caused by collapse of trench during employment

None

Richard Taylor

2 days

17/04/04

Death in police custody

None

John Macdonald

Grampian Highlands and Islands at Stornoway

5/04/04

Death at sea in the course of employment

All fishermen would benefit by the development of suitable personal floatation devices which can be worn at all times when working on board any fishing boat without hindrance to the wearer. These devices should be approved and regulations put in place to make their use compulsory.

A very high profile warning should be included in the advice to all crew members of all sea-going vessels about the inadvisability of going to sea when under the influence of alcohol. This should emphasise the very considerable danger of there still being too high a blood-alcohol level in the bloodstream the morning after a heavy drinking session. Such amplified advice should always be included in any safety course and in any reminders or refreshers which may take place in training courses.

Fishing and Code Vessel Safety Branch
Bay 2/05
Spring Place
105 Commercial Road
Southampton
SO15 1EG

E-mail:fishing@mcga.gov.uk

Tel: 023 8032 9524

John McKelvie

Tayside Central and Fife at Dunfermline

29/03/04

Head injury caused by fall while under the influence of alcohol

Consideration should be given to the provision of supervised accommodation to which persons arrested or detained under the influence of alcohol might be admitted. Such provision would require to have a degree of medical supervision and be subject to a regime of checking or observation similar to that which currently exists for dealing with vulnerable patients in custody.

Consideration should be given to defining circumstances when the police should inform a police surgeon that a vulnerable person is in custody.

Where possible, all relevant information should be recorded on an Ambulance Report Form. Where possible, the form should be completed before the handover of a patient to admitting hospital staff. Where the handover is urgent or emergency medical treatment has to take priority, such information may require to be given verbally. In such cases it is important that when the form is completed after the event that all the information given verbally is included.

Dr Frances Elliot
Medical Director
NHS Fife
Hayfield House
Hayfield Road
Kirkcaldy
KY2 5AH

Tel: 01592 643355 ext. 8077

E-mail: frances.elliot2@nhs.net

Norma Graha
Deputy Chief Constable
Fife Constabulary
Detroit Road
Glenrothes
Fife
KY6 2RJ

Tel: 01592 418888

Ms Shirley Rogers
Director of Human Resources
Scottish Ambulance Service
National Headquarters
Tipperlinn Road
Edinburgh
EH10 5UU

Tel: 0131 446 7017

E-mail:srogers@ scptamb.co.uk

28/03/04

Death in hospital - Alcoholism

John Hunter

14/03/04

Collapsed at work

Lothian and Borders at Linlithgow

19 days

28/02/04

Death in hospital

The appropriate authorities should ensure that full and legible notes are made, using standard abbreviations or phrases, so that these notes can be readily read by anyone involved in the care of the patient and at shift handovers.

Dr Charles Swainson
Medical Director
NHS Lothian
Deaconess House
148 Pleasance
Edinburgh
EH 8 9RS

Tel: 0131 536 9135

E-mail:charles.swainson@ lhb.scot.nhs.uk

Paul Algie

South Strathclyde, Dumfries and Galloway at Dumfries

26/02/04

Murdered by strangulation whilst in Dumfries prison

None

Carmella Kerr

South Strathclyde, Dumfries and Galloway

03/02/04

Death in hospital

1) It should be emphasised to all grades that there is a necessity to make proper full intelligible and legible notes of observations that they make, any action which they carry out and any action which they intend others to carry out: in the last case, who is to carry it out should be specified.

(2) In regard to a protocol for requesting a surgical review - indeed any inter-departmental review - this should always be made by and to at least a middle-grade member of staff in the referring and referee departments.

(3) The protocol for chasing up an inter-departmental review should have a time limit put on it and should not be left to individuals to estimate what is a "reasonable time". If not carried out, the referring SHO should be obliged to consider whether or not a further prompt is required and should record that he or she has so considered in the notes and either decided to wait longer or to repeat it - and should assign in the notes a reason for that decision.

(4) The system for ordering X-rays and other radiological procedures should be re-examined with a view to simplification and that all staff who are authorised to make such requests be clearly instructed as to the way in which the radiology department receives and treats them and as to the implications of the content of such requests and the time limits in which the radiology department will carry them out.

Dr Robert Masterton
Medical Director
Eglinton House
Ailsa Hospital
Dalmellington Road
Ayr

Tel: 01292 885863

E-mail:robert.masterton@ aaaht.scot.nhs.uk

North Strathclyde at Greenock

19/01/04

Death of new born baby

Argyll and Clyde Health Board (now NHS Greater Glasgow and Clyde) should review its procedures with regard to consultant paediatricians on duty contacting and supporting the parents of children who are admitted.

Agreement should be reached as to whether it is possible for a consultant Paediatrician to be sent to the community midwife unit to assist midwives, if one is available, and a suitable protocol put in place.

The Health Board should consider in more detail how the transfer of a sick baby could be effected by the Neo-natal Transfer Team from the midwife-led unit to a consultant-led unit.

The Health Board should review their procedures for counselling and supporting parents of a child in the aftermath of a tragic event.

Dr Brian Cowan
Medical Director
South Glasgow Acute Hospitals Division
Southern General Hospital
1345 Govan Road
Glasgow
G51 4TF

Tel: 0141 201 1311

E-mail:brian.cowan@ sgh.scot.nhs.uk

Moira Pullar

Airdrie

3 days

17/01/04

Death in hospital

George McGarry

South Strathclyde, Dumfries and Galloway at Ayr

4 days

15/01/04

Death in hospital

None

15/12/03

Head injury due to road traffic accident

Tayside Central and Fife at Kirkcaldy

28/11/03

Death in hospital

None

David Yardley

South Strathclyde

Dumfries and Galloway at Hamilton

11/11/03

Death in hospital

None

Tayside Central and Fife at Kirkcaldy

09/11/03

Death in custody in hospital

Fife Constabulary should:

(1) introduce and maintain regular training of police officers as to the care and management of drug abusers;

(2) review procedures for the detention of known suspected drug abusers;

(3) review the role and responsibilities of the duty sergeant with a view to enhancing its importance;

(4) improve training in relation to the use of Cellfile so as to

(a) ensure a complete record of the time in custody

(b) ensure training on a regular basis in the use of Cellfile

(c) introduce procedures to ensure Cellfile is regularly consulted

(d) consider simplifying the use of Cellfile

(5) review the use of special risk and low risk category;

(6) consider the introduction of "special measures" as a new category;

(7) ensure that custody procedures are regularly reviewed and checked.

Norma Graham
Deputy Chief Constable
Fife Constabulary
Detroit Road
Glenrothes
Fife
KY6 2RJ

Tel: 01592 418888

Sharon Elsby

2 days

01/11/03

Pedestrian hit by car

Regular checks should be conducted to ensure that the verges of roads are kept clear and to ensure that where there is overgrowth from adjoining hedges the statutory notice procedure is promptly dealt with to ensure that the verges are open, clear and wide enough for a pedestrian to use them.

There should be reasonable warning given to pedestrians on each side of the open section of The Wisp that there is ahead an area of half a mile in which there are no pavements and where great caution should be exercised.

A traffic survey be conducted to consider whether or not a restricted speed limit should be imposed on the section of The Wisp where this accident occurred in addition to ensuring that existing signs and road markings are clear and visible at all times.

Lindsay Haddow
Principal Officer
Transportation Policy
Midlothian Council
Tel: 0131 271 3501

Ian Dickinson
Acting Deputy Chief Constable
Lothian and Borders Police
Fettes Avenue
Edinburgh
EH4 1RB

Tel: 0131 311 3131

Grampian Highland and Islands at Inverness

30/10/03

Death in hospital

None

Sean McCue and

Keith Moncrieff

11/09/03

Death caused by inhalation of hydrocarbon vapours during course of employment

10/09/03

Crush asphyxia caused by an accident during course of employment

1. Consider whether any action is required in relation to existing vehicles with auto reverse braking systems.

2. Consider reviewing the relevant regulations with a view to requiring additional testing of all new vehicles with auto reverse breaking mechanisms in order to eliminate any movement of the vehicle following upon the application of lateral pressure.

Department of Transport
Great Minster House
76 Marsham Street
London
SW1P 4DR

Fax: 020 7944 9643

road.safety@ dft.gsi.gov.uk

Thomas McMahon

02/09/03

Severe head injury due to fall from height in the course of employment

Thomas Meecham

29/08/03

Sudden death at home

Where there is an urgent need to contact a patient being called in for surgery, there should be a set system in the Department of Cardiothoracic Surgery at the Western Infirmary, Glasgow for following up a message left for a patient on a telephone answering machine asking the patient to make contact where the patient fails to respond to the message with a time appropriate to the urgency of the case.

Dr Brian Cowan
Medical Director
South Glasgow Acute Hospitals Division
Southern General Hospital
1345 Govan Road
Glasgow
G51 4TF

Tel: 0141 201 1311

E-mail:brian.cowan@ sgh.scot.nhs.uk

01/08/03

Road traffic accident during course of employment

Christine Reid

South Strathclyde Dumfries and Galloway at Lanark

14/07/03

Death in hospital

None

28/05/03

Death in Hospital

05/05/03

Suicide at Barlinnie Prison

1. That the prison look at introducing a more formalised set of cards in various languages, with various words and phrases that were found to be helpful in Mr Wu's case.

2. That the Scottish Prison Service do not delay in completing an assessment of the viability of introducing Language Line.

3. Ensure that the kitchens in establishments can provide a nutritious diet which meets the cultural and religous needs of all. Failure to do that could well amount to a breach of statutory obligations under Race Relations legislation.

Jim O'Neill
Communications Manager
Scottish Prison Service
Room 338
Calton House
5 Redheughs Rigg
EH12 9HW

Tel: 0131 244 8476

E-mail:gaolinfo@sps.gov.uk

Adam Robert

South Strathclyde, Dumfries and Galloway at Hamilton

29/04/03

Sudden death at home

None

29/05/03

13 days

(b) The failure of the management of Ninewells Hospital to respond effectively to requests from Dr. Jones to make a sufficient number of beds available to accommodate the average daily intake of Ward 15, the acute medical admissions ward, so that patients arriving for admission would not require to suffer the indignity of being left on a trolley in a corridor for hours before properly being admitted;

(c) The failure of the management of Dundee City Council Social Work Department to appreciate the need for a system whereby residents in residential homes were accompanied on admission to hospital for in or out-patient treatment or assessment either by a relative or a carer and that in either event, to asssist with the presentation of a proper history for the patient, the care home notes should have accompanied the resident; and that no patient should be discharged from being an in-patient in hospital unless a relative or carer is present to accompany the resident back to the residential care home, where the particular resident's incapacity is of such a degree, as was Roddy's, that the resident would not have the capacity to consent to the medical treatment in contemplation;

(d) The failure on the part of Dorctors and the management of Ninewells Hospital, more generally, to appreciate the need to eliminate human error so far as possible, in persisting in instructing or permitting the manual transposition of blood test results from the CentralVision computerised records system to the patient's file, when a screen and printer were available to facilitate a print out of the results; and a failure by Doctors, and the management of Ninewells Hospital generally, to appreciate and to train doctors to appreciate the value of using the computer system available to consider comparative results rather than the single latest results when considering blood test results, so that trends and changes could be observed and used as an aid to diagnosis;

(e) The failure on the part of Doctors to complete and transmit to the general practitioners and the care home manager a proper and informative discharge note explaining the proper basis for Roddy's discharge on 17th. April, 2003, the investigations undertaken and the treatment given, the diagnosis, the prognosis, details of any planned further in or out patient treatment or review at the hospital and advice on treatment, medication or checking for symptoms which the general practitioners should carry out.

(f) The failure of the management of Ninewells Hospital to have in place a reasonable system for the preparation and issue of discharge letters; whether a discharge letter is actually necessary if an effective discharge note is properly communicated to the general practitioner is debatable, but if it is then arrangements must be established so that the letter is in the hands of the general practitioner no later than seven days from the date of discharge, and must be prepared by a member of the medical staff who was actually involved in the treatment of the patient;

(g) The failure by Dundee City Council Social Work Department in the preparation of care plans for residents of residential care homes to include in all cases a formal assessment of the resident's capacity to consent to (a) residing in a residential care home and (b) medical treatment, and to take appropriate action to promote the provision of a welfare guardian to all residents lacking either of these capacities;

(h) The failure of Dundee City Council Social Work Department to recognise as a matter of law that where a person does not have the capacity to consent to residing in a residential care or nursing home that in the absence of consent from a welfare attorney or welfare guardian with appropriate powers to sanction residence in such an establishment, or an order from a court sanctioning residence in such an establishment, that the detention of such a person in such a setting constitutes a breach of Art. 5(1) and (4) of the European Convention on Human Rights in the absence of any legal basis for the detention there of an incapacitated person and the absence of any legal process by which such detention can be regulated, reviewed and terminated and that, accordingly, there is a need to secure the appointment of a welfare guardian to such a person.

Dr Bill Mutch
Medical Director
Ashlude Hospital
Monifieth
Tel: 01382 537 819

Email: Bill.Mutch@tpct.scot.nhs.uk

Alan G. Baird - Director
Dundee Social Work Department
Tel 01382 433314
Fax 01382 433012
Email Alan G. Baird

Ronald Brown

Grampian Highlands and Islands at Fort William

22/02/03

Industrial accident in the course of employment

(1) Had the aggregate hopper [into which the deceased fell] been surrounded by a platform with guard rails surrounding the hopper and had there been a guard fitted over the hopper in the form of a series of bars, the death might have been avoided.

(2) Had Barr Limited specifically identified one or more of their employees as having overall responsibility for the safe operation of the plant and had the departure in the method of operation of the plant (in particular the change in the method of loading concrete into the plant) been monitored then the death might have been avoided.

(3) Had Barr Limited carried out a full and detailed "risk assessment" in relation to the operation of the concrete batching plant requiring to be signed by the operator of the plant (as evidence that he had been fully appraised of any attendant risks in the operation) then the deceased's death might have been avoided.

(4) The lack of a system at the time of death whereby any employee having concerns about the efficient/safe workings of the plant could register such concerns with the Company and a system whereby those concerns could be addressed and certified by the Company as having been addressed contributed towards the death.

(5) The lack of any formalised training and certification of training by a senior member of staff who had personally supervised Mr Brown operating the plant is a fact relevant to the circumstances of the death.

Barr Limited
Killoch
OCHILTREE
Ayrshire
KA18 2RL

Hannah Kemp

Airdrie

4 days

05/01/03

Sudden death at home

Medical profession and GPs in particular should be alerted to the heightened possibility of meningitis arising from infections from middle ear (otitis media).

Shona Welton
Head of Patient Affairs
Divisional Headquarters
Strathclyde Hospital
Airbles Road
Motherwell
ML1 3BW

Tel: 01698 245002

E-mail:shona.welton@ lanarkshire.scot.nhs.uk

22/12/02

Sudden death in Aberdeen Royal Infirmary

11/12/02

Death as a result of injuries sustained at Tullideph Nursing Home

(b) The care plan relating to any person, while it will require to address many aspects of the person's needs, should contain a clearly identifiable section detailing all incidents of violent or aggressive behaviour, any measures taken in response and the strategies recommended for avoiding repetition of such behaviour.

(c) The nursing home should, within an appropriate period (perhaps six weeks) refine and finalise the care plan, building on the initial assessment and social work care plan but taking account of the home's experience of the person since admission.

(d) When any elderly and mentally infirm person is transferred from one nursing home to another, whether both homes are run by the same organisation or not, the accepting nursing home should fully assess the needs of that person prior to admission. The accepting nursing home should be supplied with a copy of the social work care plan and the care plan of the previous home in advance of the transfer taking place.

(e) Where the transfer requires to take place as an emergency the accepting nursing home should nevertheless be supplied with a copy of the social work care plan and the care plan of the previous home at the time of the transfer taking place. The accepting home should then expedite a full assessment of the needs of the person.

(f) Following an emergency transfer the nursing home should promptly revise the care plan of the previous home to reflect any needs identified by the assessment process, but in any event within an appropriate period (perhaps six weeks) refine and finalise the care plan, building on the initial assessment and social work care plan but taking account of the home's experience of the person since admission.

(g) The senior nursing management of a nursing home should be aware of the detailed terms of the care plan of every person resident within the home.

(h) On each shift of staff on duty within a nursing home each member of the nursing or care staff, excluding any senior manager on duty, should require to be familiar with the detailed terms of the care plans of a group of residents so that the terms of the care plan of every resident will be known to at least one member of the nursing or care staff. Managers require to put in place systems which will allow staff time to become familiar with care plans and to monitor any changes to the plans.

(i) On a change of shift the staff member going off duty who is familiar with the care plans of a particular group of residents should communicate clearly and effectively to the staff member coming on duty who is familiar with the same group any relevant information about anything which may have occurred during the shift which bears upon the needs of any resident who is part of the group. This is in addition to any records of such information which the home may maintain.

(j) Communal areas of nursing homes such as lounges and dining rooms should at all times be monitored by a member of staff present in that area.

(k) The managers of any nursing home should have under constant review the level of staffing required to meet the changing needs of residents, regardless of the staffing levels set by the Care Commission for Scotland.

(l) There should be established clear protocols for liaison and exchange of information in relation to client/patient/resident care amongst social work, health professionals and care home managers.

Liz Norton
Director of Adult Services Regulation
The Care Commision
Princes Gate
Castle Street
Hamilton
ML3 6LU

Social work Services

27/11/02

Death in Royal Alexandra Hospital

1. Care Homes which offer a dedicated dementia Unit should ensure that trained nursing staff and staff who work as care assistants have training in the treatment of patients with dementia.

2. All nursing and care staff employed in Care Homes should be given a proper induction at the commencement of their employment and unqualified staff should be given relevant training throughout their employment.

3. Care Homes should be obliged to keep records for each member of staff detailing the nature of, and the extent of, the training which is given, and these records should be available for inspection by Officers of the Care Commission.

4. Since a proper and adequate level of staffing is fundamental to the efficient running of a Care Home, Officers of the Care Commission, when inspecting a Home, should always examine staff schedules and rotas, and where necessary interview staff, to ensure compliance at all times with the recommended staffing guidelines.

Liz Norton (Recommendation 3)
Director of Adult Services Regulation
Care Commision
Princes Gate
Castle Street
Hamilton
ML3 6BU

Tel: 01698 208150
E-mail:liz.norton@carecommision.com

Gudrun Rankin

Grampian Highlands and Islands at Fort William

22/11/02

Death in hospital

The Royal Colleges should consider their Scottish Audit of Surgical Mortality, its uses and the consequences of the way in which its reports are prepared, expressed and used.

The practice of the consultants at Belford Hospital encourages them to think primarily of transferring patients who are already seriously ill and deteriorating. This practice needs review and guidelines because it discourages surgical intervention locally.

There is advantage in the small size of the surgical unit at Belford with ease of direct oral communication but this should not mean that formal recording of notes should not be carried out as a matter of course.

Highland NHS Board and Belford Hospital should urgently review their drug administration procedures to eliminate unnecessary delays.

Highland NHS Board should review extensively their practices and procedures for discussing with patients and relatives options for treatment and keeping them properly informed in a sympathetic way of their health, condition and prognosis.

Royal College of Surgeons

Dr Alison Graham
Board Medical Director
John Dewar Building
Highlander Way
Inverness
IV2 7GE

Tel: 01463 706929

13/10/02

Death in Glasgow Royal Infirmary

(a) Consideration should be given to adjusting current guidlines and training as to the care of drunk and incapable prisoners.

(b) That consideration be given to extending such training both to patrol officers and turnkey officers.

(c) That consideration be given to the use of breathalyser machines to assist in determining the level of intoxiacation of very drunk prisoners.

(d) That custody sergeants be specifically instructed that a prisoner cannot be admitted to custody without their presence and without approval of that there be established a system whereby custody sergeants can summon assistance if they are unable to attend.

(e) That consideration be given to reviewing an extension to the availability of 'designated places' under Section 16 of the criminal procedures (Scotland Act) 1995 and/or the care and welfare of persons found in an intoxicated state.

f) Following an emergency transfer the nursing home should promptly revise the care plan of the previous home to reflect any needs identified by the assessment process, but in any event within an appropriate period (perhaps six weeks) refine and finalise the care plan, building on the initial assessment and social work care plan but taking account of the home's experience of the person since admission.

(g) The senior nursing management of a nursing home should be aware of the detailed terms of the care plan of every person resident within the home.

(h) On each shift of staff on duty within a nursing home each member of the nursing or care staff, excluding any senior manager on duty, should require to be familiar with the detailed terms of the care plans of a group of residents so that the terms of the care plan of every resident will be known to at least one member of the nursing or care staff. Managers require to put in place systems which will allow staff time to become familiar with care plans and to monitor any changes to the plans.

(i) On a change of shift the staff member going off duty who is familiar with the care plans of a particular group of residents should communicate clearly and effectively to the staff member coming on duty who is familiar with the same group any relevant information about anything which may have occurred during the shift which bears upon the needs of any resident who is part of the group. This is in addition to any records of such information which the home may maintain.

(j) Communal areas of nursing homes such as lounges and dining rooms should at all times be monitored by a member of staff present in that area.

(k) The managers of any nursing home should have under constant review the level of staffing required to meet the changing needs of residents, regardless of the staffing levels set by the Care Commission for Scotland.

(l) There should be established clear protocols for liaison and exchange of information in relation to client/patient/resident care amongst social work, health professionals and care home managers.

Ricky Gray, DCC

Strathclyde Police
173 Pitt St.
Glasgow
G2 4JS

Tel: 0141 532 2000

29/09/02

Suicide in Cornton Vale Prison

07/07/02

Death caused by an accident during the course of employment

a) That a proper risk assessment to identify the danger of a spillage of base oil from a long pipe made up of a series of connected short hoses and the consequent danger of ignition.

b) That all machinery, including the ships engines, should be shut down to remove any posssible source of ignition of the base oil in the event of a spillage.

c) That a person carrying out the work in a base oil tank should be accompanied at all times and should be supervised by a watchman to warn of any emergency.

d) That such a watchman should have the means of radio communication with the order of others involved in the operation on the quayside and with the ship'a officers on the bridge.

e) That any emergency equiptment, such as escape kits, should be available where the work is being done and where the equiptment might be needed in the event of an emergency.

f) That a toolbox talk and walk through of the work site should identify the alternative ways to exit the engine room

g) That there should be a standardised method of installation and operation of valves on the tanker and the open and closed positions of the valves should be clearly marked and signed.

Enviroco Ltd
Damhead Waste Management Centre Upperton Industrial Estate
Peterhead
Aberdeenshire
AB42 3GL
Tel: 01779 485200

Margaret Fewkes

Glasgow and Strathkelvin at Glasgow

15 days

24/06/02

Death in hospital

The creation of a system which accurately noted who had been discharged to carry out certain tasks as instructed by a consultant on a hospital ward round and ensured such tasks were followed through timeously would lead to quicker and appropriate intervention.

Dr Brian Cowan, Medical Director, South Glasgow Acute Hospitals Division, Southern General Hospital, 1345 Govan Road, Glasgow, G51 4TF

Tel: 0141 201 1311

E-mail:brian.cowan@sgh.scot.nhs.uk

22/05/02

Death caused by drowing while diving

16/03/02 - 17/03/02

Sudden Death at home caused by Diabetic Keto-Acidosis

Thomas Reardon

Airdrie

2 days

12/02/02

Killed by pipes coming loose on lorry during the course of employment

It is essential that webbing used for restraining loads should carry on it a marking indicating its braking strength and that police officers should be entitled to stop lorries carrying such loads with a view to ascertaining whether the webbing used and the method of restraint involved is sufficient to comply with the Department of Transport Code of Practice.

The Code of Practice issued by the Department of Transport requires to be amended to bring it into line with the National Association of Steel Stockholders Guidelines which recommend that headboards should be capable of withstanding 100% of the weight of the load forward.

The Code of Practice issued by the Department of Transport should be incorporated into the construction and use regulations as a standard required by all vehicles thereby entitling traffic officers to ensure that loads are secure and that danger to drivers and other road users is minimised.

Department of Transport
Great Minster House
76 Marsham Street
London
SW1P 4DR

Fax: 020 7944 9643

road.safety@dft.gsi.gov.uk

21/01/02

Crush asphyxia caused by a fall during course of employment

James Barclay

North Strathclyde at Kilmarnock

22 days

11/01/02

Suicide in Kilmarnock prison

HM Prisons Inspectorate to examine High Risk Assessment Team forms for prisoners over a period of time to ascertain whether such forms are receiving proper attention and that the weekly High Risk.

Ken Paul
Director
HMP Kilmarnock
Bowhouse
Mauchline Road
Kilmarnock

Tel: 01563 548936

Emma Frame

Lanark and Hamilton

24/11/01

Death in hospital

There should be a review of the practice and procedures whereby the procurator fiscal ascertains the wishes of the next of kin in connection with a request from appropriate medical authorities for the retention of organs after a post-mortem for the purposes of further detailed examination.

There is a need for a review in the procedure in the Royal Hospital for Sick Children at Yorkhill, Glasgow, when outpatient appointments are requested, in order to ensure that referrals are acknowledged to referring practitioners, with notification of the date offered for a first appointment or the likely timescale with which an appointment will be offered.

The appropriate authorities should consider conducting a review of the general practice of practitioners and hospital specialists when prescribing inhaled corticosteroids, with a view to assessing whether it is appropriate to issue comprehensive guidelines in relation to prescribing, specialist referral, informing patients about possible side effects, monitoring to detect side effects and ancillary matters such as the issue of steroid cards.

Crown Office and Procurator Fiscal Service

Dr Brian Cowan
Medical Director
South Glasgow Acute Hospitals Division
Southern General Hospital
1345 Govan Road
Glasgow
G51 4TF

Tel: 0141 201 1311

E-mail:brian.cowan@ sgh.scot.nhs.uk

21/10/01

Death in Police custody

That the police carry out an audit of their training schedules to ensure that every member of staff who serves in or may be called to serve in the custody suite has received the appropriate and up to date training.

William Bald
Deputy Chief Constable
Tayside Police
PO Box 59
West Bell Street
Dundee
DD1 9JU

Tel: 01382 596001

William.Bald@tayside.pnn.police.uk

Jane Constance and Elizabeth Swinscoe

Lothian and Borders at Selkirk

7/11/01

25/06/04

Deaths in hospital after period in nursing home

22/03/01

Death in hospital

30/05/01

Asphyxia caused by accident during course of employment

(i) That the Health and Safety Executive and other relevant bodies such as the Construction Industry Training Board (CITB), the Construction Industry Research and Information Association (CIRIA) and Institute of Civil Engineers should all take steps to ensure that the industry guidance and training courses for managers and operatives are updated to include reference to the circumstances of this accident, namely the risk of voids being formed outside the confines of trenched excavations in sand and gravels and in the context of tidal conditions.

(ii) Site-based training, briefings and toolbox talks are important for imparting particular knowledge and information to those involved in the excavation works in difficult and challenging conditions.

(iii) The companies which manufacture and supply trench support systems offer a free advice service to the constuction industry in relation to the suitability of particular systems for particular undertakings; this service should be utilised by temprary works co-ordinators and other persons who are responsible for deciding on the method to be used in temporary works, particularly where the excavation support is required to be deployed in difficult and challenging conditions such as on a foreshore.

Health and Safety Executive
Bedford House
59 Belford Road
Edinburgh
EH4 3EU

Tel: 0845 345 0055

Construction Industry Training Board (CITB)
Bircham Newton
King's Lynn
Norfolk
PE31 6RH

Tel: 01484 577 800

Construction Industry Research and Information Association (CIRIA)
University of Dundee
Dundee
DD1 4HN

Tel: 01382 386093

Insitute of Civil Engineers
105 West George St
Glasgow
Lanarkshire
G2 1QL

Tel: 0141 221 5276

Dennis Murray

Grampian Highlands and Islands at Inverness

23/09/00

Major head injury caused by accidental fall at work

None

John Haldane and Dorothy Morris

North Strathclyde at Oban

21/08/00

Asphyxia due to a diving accident

(1) That dive leaders of diving be assessed in person as to their suitability to lead expeditions by an officer/officers of the dive club before being permitted to undertake this task

(2) That before expedition leaders are permitted to be in sole charge of an expedition they should have completed a pre-determined number of expeditions in which they have acted as an assistant leader.

(3) That course content including timetabling are discussed personally by the 'expedition advisor' with the selected expedition leader/leaders

(4) That expedition leaders be required to personally scrutinise participating logbooks and discuss with the individual divers their relevant experience and past difficulties in diving.

(5) That divers inexperienced in the use of Nitrox gas should (a) not be permitted to dive carrying Nitrox cylinders and (b) not be permitted to dive using Nitrox gas without being certified by the club as having received instructions and tuition in the use and theory of diving with Nitrox gas.

(6) That prior to any dive in which Nitrox gas is being used the expedition leader personally certifies that the gas used has been analysed.

(7) That in all dives including 'shake down dives' the expedition leader be required to personally satisfy himself as to the remaining levels of gas in participating members' cylinders.

(8) That in no circumstances should any diver dive in the knowledge that he has any faulty equipment or with the suspicion that he has faulty equipment.

(9) That at the conclusion of each day's diving on any expedition there be a mandatory formal de-briefing session by the expedition leader at which all expedition members be required to attend.

(10) That each expedition be required to carry with it it's own lifesaving oxygen equipment and that at all times whilst diving is in progress there remain on onboard the expedition vessel a member of the expedition who is experienced and conversant with the use and handling of such equipment.

(11) That the British Sub Aqua Club issue clear guidelines as to the circumstances when it is appropriate to use 'tensioned lazy shots' and specify appropriate sizes of marker buoys and weighting to be used and in what circumstances.

(12) That in diving accidents involving a fatality there be an immediate investigation by a designated officer/officers of the British Sub Aqua Club and immediate recommendations such as are deemed appropriate in relation to procedure/practice be issued

Jim Watson, Safety and Development Manager,
British Sub Aqua Club

jimw@ bsac.com