Fatal Accident Inquiries (FAIs) are held following a death in the workplace or in cases which give rise to reasonable suspicion. They are usually held in the sheriff court, but may be held in other premises when appropriate. Summaries provide the main findings in order to assist understanding and may be published in cases where there is wider public interest. They do not form part of the reasons for the findings.

The full Determination published on the Scottish Courts and Tribunals website is the only authoritative document.

Read more about FAIs.

See the legislation.

Once a Determination is delivered, it is not the role of the sheriff to enforce recommendations made, or to ensure compliance by any person who has provided a response to recommendations.

Sophie Anne Parkinson


Oct 2, 2020

The following is a summary of the Determination of Sheriff Lorna Drummond QC in the Fatal Accident Inquiry (FAI) into the death of Sophie Anne Parkinson, aged 13, who died at her Dundee home by hanging herself on 1 March 2014.


The FAI heard evidence in relation to Sophie’s interaction with NHS Tayside Child and Adolescent Mental Health Services (CAMHS) in the period before her death.

The Sheriff found that a number of precautions could reasonably have been taken by CAMHS which might realistically have avoided Sophie’s death. These included using a structured risk assessment, considering more intensive treatment in the community, involving social work and Miss Parkinson’ family in her care, and providing further family therapy to her.

The Sheriff found that CAMHS’ systems for guiding the direction and oversight of a patient’s care during the relevant period were confusing and inadequately explained to Sophie’s family. CAMHS’ system of patient risk assessment and management, and system of communicating and recording patient care with patients was also defective.

The Sheriff found that following a number of reviews, after Sophie’s death, NHS Tayside addressed the defects in systems identified by the Sheriff. A system of complex case reviews with structured risk assessments, a lead clinician in charge of care and multi-agency involvement is now in place.

In her Determination, the Sheriff has made the following 3 recommendations:

  • that CAMHS should ensure that there is out of hours support for CAMHS’ patients and that the patients and their carers know who to contact out of hours
  • that CAMHS provide written information to patients and their carers explaining their organisational structure and the role of clinicians
  • that CAMHS investigate the viability of ‘safe space’ beds as currently provided to CAMHS’ patients of the Lancashire and South Cumbria NHS Foundation Trust.

See the Determination.

2 October 2020