Fatal Accident Inquiry Rosepark Nursing Home

At the conclusion of the inquiry Sheriff Principal Brian Lockhart issued the following statement.

“The evidence has now been concluded in this Fatal Accident Inquiry.  There have been 141 days of evidence.  There are 145 lever arch files full of documentary productions.  This Inquiry has been noteworthy both in respect of the length of the proceedings and the number and complexity of the issues that have arisen.

Normally, in a Fatal Accident Inquiry, after parties have had the opportunity of studying the notes of evidence, there is an oral hearing to enable parties to propose draft findings in fact that the Sheriff may make, and also to make submissions on the matters required by statute to be determined, namely where and when the deaths took place, the cause or causes of the deaths, or any incident leading to the deaths, the reasonable precautions whereby the deaths might have been avoided, the defects, if any, in any system of working which may have contributed to the deaths or to the incident leading to the deaths, and any other factors considered to be relevant to the circumstances of the deaths.

The issues in this Inquiry are all set out in the Petition which was presented to the court and read out at the commencement of this Inquiry.

In this Inquiry, in my opinion, it is not practicable to hold a full oral hearing at which parties will give their full submissions.  In this instance, I think it is appropriate that parties should submit written submissions for my consideration.

I have given careful consideration as to how the question of written submissions should be managed.  The Advocate Depute has indicated to the Court that he recognises that the Crown bears a responsibility to assist the Court by presenting full submissions on all the issues which the Court will by statute require to determine.  He indicated that he considered it would help to focus the issues which are actively disputed by the interested parties if they can frame their submissions in response to and, as they consider appropriate, under reference to the Crown’s submissions.  I agree that it is not appropriate that all parties lodge their submissions at the same time.  There requires to be a structure.  I think the Crown, who sought this Inquiry, should lodge their draft submissions.  Interested parties should then reply thereto and add such other submissions as they wish.  As a substantial number of the issues involve several of the interested parties, it is appropriate that all be given an opportunity to adjust their draft submissions in light of the submissions of the interested parties.

I accordingly propose that the exercise should be conducted in four stages:

1.      The lodging of draft written submissions on behalf of the Crown, setting out the Crown’s proposed findings in fact and their submissions in respect of the matters which require by statute to be determined by me.  These will be intimated to all interested parties.

2.      The lodging of draft written submissions in answer on behalf of each of the interested parties, including their response to the Crown’s submissions with, in addition, a note of their own proposed findings in fact and submissions in respect of the matters which require by statute to be determined by me.  These submissions will be intimated to all parties, including the Crown.

 3.      A period of adjustment to allow parties to adjust their draft submissions in light of what has been submitted by the interested parties.  It should be understood that interested parties may, in their various submissions, make comments to which other interested parties should, in fairness, be able to respond.  Likewise, the Crown would require an opportunity to consider any comments which may be made on its draft submissions with a view, if appropriate, to adjusting its own draft.  Written submissions in their final form will then be lodged with the Sheriff Clerk.

4.      A short oral hearing in Hamilton Sheriff Court to allow parties to make any final comment and to confirm they have nothing to add.  At that time the written submissions will be released to the Press.

I am obliged to the Advocate Depute and to Mr McBride on behalf of the interested parties for their agreement to this proposal and to the following timetable:

1.      Draft submissions by the Crown to be lodged with the Sheriff Clerk at Hamilton by 12 November 2010.  I accept the submission of the Advocate Depute, which was accepted by all interested parties, that having regard to the volume of the evidence and the complexity of some of the issues which arise, that is a reasonable period for the Crown to do justice to the case.

 2.      Draft submissions to be lodged by the interested parties with the Sheriff Clerk at Hamilton by 21 December 2010.  I consider this gives interested parties a reasonable time to respond to the Crown’s submissions and to make their own submissions.

3.      Submissions in their final form, after adjustment, to be lodged with the Sheriff Clerk at Hamilton by 19 January 2011.

4.      Oral hearing in Hamilton Sheriff Court on 27 January 2011.


There is a very considerable amount of material that I require to study and digest.  This study will be ongoing and will continue as I receive the written submissions in terms of the timetable which I have set out.  I am conscious of the many significant issues which have been canvassed at this Inquiry and their importance both to the individuals and organisations involved and in respect of the administration and regulation of Care Homes.  These issues demand my careful consideration.  I shall do my best to issue my Determination as soon as practicable after 27 January 2011.

I would finally again express the sympathy of all involved to the relatives of those who lost their lives at Rosepark”.