FAI DETERMINATION SUMMARIES
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.
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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.
Leylan Forte
Jan 21, 2022
A Fatal Accident Inquiry (FAI) held at Dundee Sheriff Court heard that Leylan Forte died on 27 April 2015 in an ambulance parked outside his Montrose home.
The cause of his death was acute dehydration and electrolyte disturbance secondary to norovirus, with the possible contributory factor of cerebral palsy.
Leylan was born prematurely and had a brain injury. He was treated neonatally for withdrawal as a result of his mother’s drug use during pregnancy. He had partial sight and cerebral palsy. He required input from multiple different professionals, however he was frequently not taken to important medical appointments. He was seen regularly at home by his health visitor and dietician and prescribed supplements for being dangerously underweight.
On the morning of 25 April 2015, he started to vomit. His parents made several calls to NHS 24, the second at around 6am on 27 April. The nurse who answered this call determined that Leylan required to be seen within four hours and advised his father to take him to the GP practice as soon as he could when it opened at 8 am.
The inquiry heard that NHS 24 relies on GP practices to proactively provide a Key Information Summary for vulnerable patients. There was no such note for Leylan.
The NHS 24 nurse testified that if he had been aware of Leylan’s medical background including the fact that he had been born prematurely and was underweight (which would have informed the likelihood of dehydration), he would have sought an ambulance within the hour rather than ask the parents to contact the GP surgery later that day when it opened. The nurse also admitted that he could have asked more probing questions about Leylan’s condition.
It was accepted however, that before Leylan’s death in 2015, such medical summaries were normally provided for terminal patients and their use had only recently widened.
Later on the morning of 27 April, the parents requested a home visit from the GP practice. One of the doctors phoned the parents and was told that Leylan was keeping down some water and urinating. Based on this information, she arranged to make a house visit following her morning surgery. However when she later received an urgent call from Leylan’s father, she departed for the family home. When she arrived she immediately told the parents to phone for an ambulance, which arrived 16 minutes later, and ordered oxygen from the practice. However, the emergency services could not save Leylan and he died at at 12:28.
Sheriff Jillian Martin-Brown wrote in the FAI Determination: “I am of he view that the use of the Key Information Summary of the Emergency Care Summary by the deceased’s GP practice to note his low BMI and parental vulnerabilities might have avoided the deceased’s death … I am pleased to hear that greater use is being made of the Key Information Summaries after the COVID-19 pandemic. However, in light of the lessons learned from this inquiry, I think it would be useful to recommend that GP practices should make greater use of Key Information Summaries on Emergency Care Summaries where appropriate to improve information sharing between GP practices and NHS 24.”
Sheriff Martin-Brown also noted the delay in the inquiry coming to court. She wrote: “The conclusions of this FAI are essentially the same as those reached by the GP practice and NHS 24 following their own investigations completed within one month and three months of the deceased’s death respectively, namely that it may have been helpful for the GP practice to highlight poor nutrition to NHS 24 and that the information available to the second nurse practitioner should have alerted him to the fact that the deceased was at greater risk of dehydration. If the purpose of this discretionary FAI was to draw wider attention to those lessons learned and avoid future deaths, then it ought to have taken place much sooner after the deceased’s death. Otherwise, it is difficult to understand how the public interest is served by an inquiry taking place six years after the deceased’s death covering the same issues.”
The Sheriff and all parties expressed her sincere condolences to Leylan’s family.
The full Determination published on the Scottish Courts and Tribunals website is the only authoritative document.