This is a summary of the key findings and recommendations arising from the 2025 Independent Review of Fatal Accident Inquiries (FAIs) chaired by Sheriff Principal Ian Abercrombie KC.
The review was commissioned by the Scottish Government in response to sustained concerns regarding delay, inconsistency and the experience of bereaved families in FAIs concerning deaths in custody.
Although the review is confined to custodial deaths, its conclusions have wider relevance for other bodies who may participate in FAIs.
Background and Scope
The review examined the operation of the FAI system in relation to deaths occurring in prison and police custody. Its remit included the effectiveness and timeliness of investigations, the experience of families and identifying any barriers faced by them in terms of the process and the timescales involved. The review was tasked with making tangible recommendations.
The report’s overarching conclusion is that the system, as presently operating in relation to deaths in custody, is not functioning as effectively or compassionately as it should. Delay was identified as a systemic problem, often occurring at multiple stages: investigation, prosecutorial preparation, court scheduling and the issuing of determinations. The cumulative effect of these delays was found to undermine confidence in the system and dilute its preventative purpose. 34 recommendations were made and directed to various bodies. The recommendations cover: the investigation of deaths; support for families; preparation for an FAI; the FAI itself; delays and time limits; the Sheriff’s decision (called a determination in an FAI) and follow up on recommendations.
Family Experience and Transparency
A theme which runs through the review is the experience of bereaved families. Evidence gathered during the review described a process that can feel protracted, complex and insufficiently explained. Families reported experiencing: a lack of understanding about FAIs and their purpose; a lack of support and information; financial barriers; inaccessibility of the court process; and a lack of follow through.
The report calls for a more trauma-informed and transparent approach, with earlier access to legal aid and clearer communication from the outset. It recommends that a First Notice in deaths in custody should be issued within six months, enabling earlier judicial oversight and engagement.
Investigation and Structural Reform
The review proposes structural reform to the investigation stage of deaths in prison custody, recommending that such cases be handled by a specialist team within Police Scotland’s Major Crime Division. If measurable improvement is not achieved, the creation of an independent investigative body is contemplated.
The review also recommends that the frequency and content of training for sheriffs on FAIs should be considered and that only sheriffs who have received specific training should hear FAIs.
Timeliness and Accountability
The report proposes clearer expectations around timescales for investigations and determinations, including a working aim that determinations be issued, at the latest, within one year of the date of death. It also recommends annual reporting by the agencies involved in FAIs on their performance and explaining any delays.
Of particular significance is the recommendation for a national oversight mechanism, independent of the judiciary and operational agencies, to monitor implementation of FAI recommendations and report annually to the Scottish Parliament. If adopted, this would represent a material development. At present, while responses to recommendations must be provided within eight weeks and are published, there is no formal system of ongoing monitoring. The proposed reform would introduce a greater degree of sustained scrutiny.
Conclusion
The review chaired by Sheriff Principal Ian Abercrombie KC represents a significant examination of the FAI system and articulates a clear expectation of improvement. The central message is that FAIs must be timely, transparent and effective in achieving their ultimate purpose of reducing preventable deaths.
If you would like to consider Sheriff Principal Ian Abercrombie KC's report in more detail, it can be accessed here.
