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.

Mark Johnston


Aug 30, 2021

A Sheriff has ruled that the death of a man stabbed by another man being treated for paranoid schizophrenia could not have been prevented by the medical staff providing the treatment.

The following is a summary of the Fatal Accident Inquiry Determination published on the Courts website which is the only authoritative document.

A Fatal Accident Inquiry held at Dundee Sheriff Court heard that David Reid stabbed Mark Johnston within three days of discharging himself from hospital.

In Court, David Reid was found not guilty of a crime by reason of insanity and a compulsion order and restriction order without a limit of time were imposed. He is now detained at the state hospital at Carstairs.


Sheriff Jillian Martin-Brown ruled that, based on the law, expert evidence, and submissions made to the Inquiry, no recommendations could be made.

The Inquiry heard that David Reid had sought medical attention in Dundee aware that he was having problems with his schizophrenia and hallucinations. No beds were available in Tayside but one was provided to him at the Royal Cornhill Hospital in Aberdeen.

Following days of assessments at the hospital, David Reid said that he was no longer having hallucinations and intended to leave. Attempts were made to persuade him to stay. However, he did not meet the five necessary criteria to be legally detained (see paragraphs 69 – 70 of the Determination) and he was assessed as having sufficient insight to manage his illness.


The scope of the Inquiry was restricted to:

  • the decision not to detain David Reid for in-patient care
  •  information sharing between Tayside Health Board and Grampian Health Board.

No findings were sought by any party in relation to the decision not to detain David Reid.  Counsel for David Reid submitted that detention was a precaution that could reasonably have been taken, but accepted that even if David Reid had been detained it could not be said that such detention might realistically have resulted in the death being avoided. 

In the Findings and Recommendations of the Determination at paragraph 84, the Sheriff states: “In light of Dr Robinson’s evidence that the five criteria for short-term detention under section 44 of the 2003 Act were not met, which was supported by the independent expert Dr Tuddenham, I do not consider that detaining David Reid was a precaution which could reasonably have been taken.

“Furthermore, in light of Dr Robinson’s evidence of the short timescale for review of detention, which was supported by Dr Scott, I do not consider that even if David Reid had been detained to allow for fuller assessment, that would have resulted in David Reid being detained for long enough such that the death of the deceased might realistically have been avoided. The evidence of how David Reid presented after his discharge did not suggest that he ought to have been detained.”

The Inquiry heard evidence that the information sharing between the health boards followed good practice.

In her Conclusion at paragraph 85 of the Determination, the Sheriff wrote: “It is tempting to assume that because David Reid killed Mark Johnston within three days of discharging himself against medical advice from Royal Cornhill Hospital, something must have gone wrong in terms of the exercise of clinical judgement. However, that was not borne out by the factual or opinion evidence in this Inquiry. It is not clear why David Reid’s mental state deteriorated after his departure from Royal Cornhill Hospital but that was not due to any failings on the part of the medical professionals who worked with him, nor the system within which they worked.

“I wish to express my sincere condolences to Mark Johnston’s family and friends, which were echoed in the submissions made by all parties.” 

You can read the Determination here