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.

Edward Simpson

Dec 18, 2025

Sheriff Jillian Martin-Brown has issued her determination following a fatal accident inquiry in to the death of Edward Simpson, who died at Ninewells Hospital in Dundee on 18 March 2022.

The Sheriff's full determination is available to read on the Scottish Courts and Tribunals website

Background

Mr Simpson was a prisoner at HMP Castle Huntly serving a life sentence for murder. He had been released on licence but was recalled to prison in 2016 after being found in possession of a knife and was sentenced to five years imprisonment for a contravention of section 49 of the Criminal Law consolidation (Scotland) Act 1995 in October that year.

Mr Simpson had serious underlying health conditions. In the months prior to his death Mr Simpson had been in hospital a number of times.

On 6 February 2022 he was admitted to hospital and was confirmed as being positive for COVID-19. He was discharged from hospital on 8 February and was clinically stable. He was isolated in the Bruce Wing at HMP Castle Huntly on his return to the prison.

On 1 March 2022 Mr Simpson was admitted to Ninewells hospital after reporting breathing difficulties and had low oxygen saturation levels, and confirmed as remaining positive for COVID-19. He was discharged on 4 March and seemed to be improving on 7 March.

Mr Simpson was readmitted on 8 March and was treated for pneumonia. He was transferred to High Dependency Unit on 15 March as he was gravely unwell and required end of life care. A Do not Attempt Carido-Pulmonary Resuscitation (DNACPR) form was completed and explained to Mr Simpson. He died at around 19:20 on 18 March.

A death certificate was issued by Dr Margaret Whyte, Doctor, Ninewells Hospital in the following terms:

I. (a) pneumonia;

I. (b) immunosuppression;

I. (c) myleoperoxidase vasculitis – myeloperidase positive;

II. severe emphysema; and

II. COVID-19 disease.

Mr Simpson had advanced lung disease and It was determined that the additional burden of immunosuppression increased his chances for a more severe outcome. COVID-19 had a minimal Impact, if any on Mr Simpson. There was no conclusive evidence that he had died of COVID-19 complications.

DIPLAR

DIPLAR (Death in Prison Learning, Audit & Review) is completed after the death of any person in prison custody in Scotland and provides a system for SPS and the applicable NHS Board to record any learning and identify actions following a death. The following were noted as areas for learning and development for Tayside Health Board after the death of Mr Simpson:

further development and training for all staff on long term conditions;
the use of the SBAR (Situation, Background, Assessment and Recommendation) format for recording long term condition assessments and monitoring consultations;
embed clinical supervision model for nursing staff within primary care team; and
further development of nursing staff in clinical skills such as chest auscultation and interpretation of blood results.

Further development and training for all NHS staff on long term conditions was listed as a DIPLAR learning point because of the fluctuation in Mr Simpson’s overall health in the months leading up to his death. It was identified that NHS staff training on chronic illnesses would help in identifying indicators of deterioration and need for escalation. NHS staff within HMP Castle Huntly have now implemented that training.

The SBAR format keeps records easy to navigate, precise and easy to manage. The SBAR format is now more widely used by NHS staff in HMP Castle Huntly.

Finding and recommendations

Sheriff Jillian Martin-Brown’s findings were in line with the conclusions of the DIPLAR. There was good information sharing between SPS and Tayside Health Board and Mr Simpson received compassionate care. There was no evidence to suggest any precautions could have been taken or any system defects, which might have prevented his heath.

Accordingly Sheriff Martin-Brown made no recommendations.