对2010年至2013年期间苏格兰监狱羁押期间83起死亡事件的致命事故调查。

Fatal accident inquiries into 83 deaths in Scottish prison custody: 2010-2013.

作者信息

Bird Sheila M

机构信息

Cambridge University's MRC Biostatistics Unit, UK; and Edinburgh University's College of Medicine and Veterinary Medicine, UK.

出版信息

BJPsych Open. 2020 Oct 30;6(6):e132. doi: 10.1192/bjo.2020.121.

DOI:10.1192/bjo.2020.121

PMID:33121556

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC7745234/

Abstract

BACKGROUND

The only non-legal reference in Lord Cullen's Review of fatal accident inquiry (FAI) Legislation in Scotland (2009) was my audit of FAIs into 97 deaths in prison custody in Scotland, 1999-2003: recommending that waiting time from prisoner death to end of FAI should be less than 1 year for 90% of FAIs, and epidemiological rules for FAIs to have a written determination versus formal findings.

AIMS

Audit of FAIs into 83 deaths in Scottish prison custody in the period 2010-2013.

METHOD

Assessement of waiting times from prisoner death to end of FAI; dissemination of written determinations; self-inflicted death rate per 1000 prisoner-years; cause of natural deaths; and yellow card submissions. Detailed cross-checking was nec37essary between Scottish Prison Service and courts' websites and the Scottish Fatalities Investigation Unit.

RESULTS

Of 83 FAIs into deaths in Scottish prison custody, 2010-2013, 37 (45%) were long-awaited (ongoing >2 years after the prisoner's death); 16 (19%, 95% CI 11-28%) beyond 3 years. Of 37 long-awaited FAIs, 27 made written determinations but only 12 of these (44%) were published. Self-inflicted deaths numbered 36: 1.1 per 1000 prisoner-years (95% CI 0.75-1.48). Of 47 deaths from natural causes, cardiovascular disease accounted for 23 (49%, 95% CI 34-63%); liver disease was implicated in 10 of 47. To support pharmacovigilance, submissions were made to Medicines and Healthcare Regulatory Agency for eight deaths (10%, 95% CI 4-19%).

CONCLUSIONS

FAIs into prisoner deaths in Scotland are too long-awaited given that four (5%) identified precautions that could have prevented death.

摘要

背景

卡伦勋爵对苏格兰致命事故调查（FAI）立法的审查（2009年）中唯一的非法律参考文献是我对1999 - 2003年苏格兰监狱羁押期间97例死亡的FAI审计：建议90%的FAI从囚犯死亡到FAI结束的等待时间应少于1年，以及FAI的流行病学规则要有书面裁定与正式调查结果。

目的

对2010 - 2013年期间苏格兰监狱羁押的83例死亡进行FAI审计。

方法

评估从囚犯死亡到FAI结束的等待时间；书面裁定的传播；每1000囚犯年的自杀死亡率；自然死亡原因；以及黄卡提交情况。苏格兰监狱管理局、法院网站和苏格兰死亡调查股之间进行了详细的交叉核对。

结果

在对2010 - 2013年苏格兰监狱羁押期间死亡的83例FAI中，37例（45%）等待时间过长（囚犯死亡后持续超过2年）；16例（19%，95%置信区间11 - 28%）超过3年。在37例等待时间过长的FAI中，27例做出了书面裁定，但其中只有12例（44%）公布。自杀死亡人数为36例：每1000囚犯年1.1例（95%置信区间0.75 - 1.48）。在47例自然死亡中，心血管疾病占23例（49%，95%置信区间34 - 63%）；47例中有10例与肝病有关。为支持药物警戒，向药品和医疗保健监管局提交了8例死亡报告（10%，95%置信区间4 - 19%）。