Professor Angela O'Hagan

The report draws from a major ‘Family Listening Day’ attended by 33 bereaved relatives, revealing a fatal accident inquiry (FAI) system in Scotland that families describe as confusing, slow, defensive and dehumanising.

INQUEST, a charity with expertise in state-related deaths, was commissioned by the SHRC to facilitate the Family Listening Day.

The report focuses on documenting lived experience in Scotland, placing family testimony at the heart of its findings. Families describe being ignored when raising concerns about their loved ones’ safety, being treated without dignity after the death occurred, and navigating long, complex investigation processes alone.

The report has been submitted by the SHRC to the Fatal Accident Inquiry Review chaired by Sheriff Principal Ian Abercrombie.

The review was announced by the Scottish government in January, following a report from the SHRC which criticised lack of action on reducing deaths in state custody in Scotland, and in particular, lack of progress to review the FAI system around deaths in places of detention.

Scotland has a legal obligation under Article 2 (right to life) of the European Convention on Human Rights to investigate deaths in custody effectively, transparently and with family involvement.

Families say their warnings about serious risks were ignored. A relative said: “We tried to warn them … four hours later we got the call saying he was dead.”

Notification of death was often described as cold or chaotic. A parent commented: “I was told he’d hung himself, then told he hadn’t. I’ll never forget that moment.”

A family member said: “They didn’t call him by his name, just the body.”

Investigations were experienced with long delays and little communication. One parent remarked: “You’re frozen in time with no answers.”

Families described fatal accident inquiries as intimidating and adversarial, despite being presented as fact-finding hearings. A parent recalled: “It feels like you are the one on trial.”

Families who spoke at the participatory event run by the SHRC and INQUEST, set out recommendations for the independent review to consider, including:

• humane, coordinated communication after a death;
• independent points of contact for families;
• legally enforced timescales;
• guaranteed legal representation;
• trauma-informed practice;
• specialist sheriffs for deaths in custody; and
• independent oversight of FAI recommendations.

Professor Angela O’Hagan, chair of the Scottish Human Rights Commission, said: “Scotland will only improve its system of investigating deaths if decision makers hear, truly listen to and take account of the experiences of families who have had to go through this investigation process as it has functioned to date.”

“Scotland has a very high rate of deaths in its places of detention, and these deaths are rising. This is unacceptable and is a grave human rights concern.”

“We simply cannot continue in this seemingly endless cycle of new reviews and recommendations while deaths in detention continue to rise.”

Deborah Coles, executive director of INQUEST, said: “This report must be a wake-up call for fundamental reform of the system for investigating deaths in custody in Scotland.

“Families describe the legal process after a death as being another layer of harm, extending their grief for years. It also fails to deliver truth, accountability, and the prevention of future deaths. It cannot be overstated just how cruel, and retraumatising families’ experiences are. This is unacceptable.

“The families who participated in this day did so in the hope that other do not have to suffer in the way they have. The power of this report is only as good as its implementation. Families’ testimony and recommendations must be translated into meaningful action.”