No one would believe it could take nearly a decade to give answers to a grieving mum about her son’s tragic death in an Aberdeen jail cell at Kittybrewster police station, but it has.
Even after Aberdeen Sheriff Court finished hearing the last evidence on Warren Fenty’s final moments, more than two years would pass before a sheriff published the case’s conclusions.
Warren died of a drug overdose in June 2014.
But never before in Scotland has it taken so long to start and end a probe into someone’s sudden and unexpected death.
As part of the arduous process, three years of it was spent with the matter “sitting on someone’s desk”, Sheriff Principal Derek Pyle suggested as he criticised the Crown Office’s delayed investigation during proceedings.
The fatal accident inquiry (FAI) was plagued by issues.
Five aborted publication deadlines by the Scottish Courts and Tribunals Service (SCTS); the removal of the original presiding sheriff after Morag McLaughlin failed to deliver her conclusions for “personal medical reasons”; missing evidence and IT issues with accessing the contents of a memory stick.
Warren’s mum Sharon, 54, then faced one last wait as the sheriff principal left the country for “previously arranged leave abroad for three weeks” after missing a deadline he set himself.
But, now, Sheriff Principal Pyle has finally revealed his long-awaited ruling that the vulnerable 20-year-old’s demise was “likely” avoidable were it not for “institutional failures” by Police Scotland.
He added the force failed to take “precautions” and missed “opportunities” to save his life.
Unconscious Warren Fenty taken to hospital before arrest on suspicion of drug offences
In the early hours of June 28, 2014, Mr Fenty was found lying unconscious at a house in Aberdeen, having taken an apparent overdose.
He was taken by ambulance to Aberdeen Royal Infirmary where he received treatment for having consumed too much methadone at the hospital’s high dependency unit.
Mr Fenty was shadowed by police officers who’d been instructed to immediately detain him upon his discharge from NHS Grampian’s care.
After the young man ignored medical advice and prematurely discharged himself from the hospital, he was arrested on suspicion of offences under the Misuse of Drugs Act 1971.
By 7.07am the following day, an unresponsive Mr Fenty was discovered in his cell at Kittybrewster custody centre where paramedics, who arrived just 12 minutes later, were unable to revive him.
The detainee was pronounced dead at 7.25am with the cause of death determined to be methadone intoxication.
However, it would be nearly 10 years before a definitive report would be published, revealing what went catastrophically wrong after a series of events.
Crown’s three-year gap of inactivity revealed as one cause of delays to FAI proceedings
The process began with internal reviews of procedures within the north-east health board and Police Scotland.
An independent probe by the police watchdog, which was completed around four months after Mr Fenty’s death, along with the production of a post-mortem report took just under a year altogether.
Then, for more than three years, the Crown Office and Procurator Fiscal Service (COPFS) – responsible for the investigation of all sudden, suspicious, accidental and unexplained deaths – did nothing to progress the case.
The controversial gap was revealed in a timeline document that was queried by Sheriff Principal Derek Pyle during an emergency hearing to determine the future of the troubled inquiry in February this year.
“I asked the Crown if they wanted to say any more about that and I understand that the Crown’s position is that they have nothing further to say,” the sheriff principal remarked.
He asked fiscal depute Muhammad Sadiq: “Should I therefore conclude that it either sat on someone’s desk and nobody did anything about it? Or was it simply not before a member of the Crown during that three-year period?”
Mr Sadiq replied: “My Lord, there is no other explanation other than what is already contained within the timeline that was lodged with your Lordship’s clerk.
“I do accept there was a three-year gap.”
It has since emerged that the COPFS only requested hospital and GP records and CCTV recordings in July 2018 and belatedly asked witnesses for their expert reports in February 2019.
In his determination, Sheriff Principal Pyle said: “While there were changes in staff during that time, why it took seven months for this process is unexplained.”
The Crown Office finally referred Warren Fenty’s case to the SCTS in March 2020, almost six years after he lost his life.
The first day of the FAI’s court proceedings eventually took place on September 14, 2021, lasting two weeks that month until more hearings resumed in February 2022.
Understandably, to a degree, the Covid pandemic had also played a role in the delays.
“It is difficult to co-ordinate so many diaries,” the sheriff principal also noted in his 39-page report summarising the evidence of 19 witnesses heard by Aberdeen Sheriff Court over 12 days.
Referring to the Crown’s conduct, he added that “over a period of five years and two months only some 22 months were usefully spent”.
Sheriff removed after repeated ‘failure’ to deliver inquiry’s conclusion
Although the inquiry took the last witness’s evidence in February two years ago, by around the middle of January this year it was finally time for presiding Sheriff Morag McLaughlin to go.
Her boss – Grampian’s most senior sheriff – removed her from the inquiry after four deadlines to publish the case’s conclusions had been missed.
On one of those occasions, the SCTS aborted publication less than 24 hours before the report was due to be made public.
Mrs Fenty had not been told and was in tears over the phone as The Press and Journal updated the distraught woman on the sudden U-turn.
In the last hearing to be held by the inquiry, the sheriff principal revealed that he had become aware of severe delays to the FAI’s progress almost a year ago, in March 2023.
“I’m not blameless in that,” he admitted to the court, adding: “That is a failing by me.”
He explained that the system he inherited to monitor his sheriffdom’s performance did not include FAIs on the list of ongoing cases.
Further explanation of the lapses were offered in his determination: “I cannot explain the failure of the sheriff … other than to say it was for personal medical reasons.
“I do however myself accept that the problem should have been identified by me six months or so before it was.
“I have always had a system in place for the monitoring of written work by the sheriffs in the sheriffdom, but that did not include fatal accident inquiries, the reason being that until now it has never been a problem.
“But I accept that I should have. It would have meant that by three months after the final date of the hearing I would have been asking questions.
Sheriff Principal Pyle added: “In the event, I was unaware of the problem until March last year, some seven months later.
“I cannot go into what happened after that, except to say that I was ever conscious that other than the eventual issue of the determination by the sheriff the only, most unattractive, alternative was a rehearing of the inquiry, a step I was only very reluctantly willing to take – albeit that was indeed what happened.
Missing evidence was another hurdle in getting out long-awaited findings
He also detailed the background concerning himself missing the fifth publication deadline.
“I promised parties that I would issue the determination four weeks after the last procedural hearing.
“It was only during the course of considering the evidence that I discovered that I had not been provided with all of the productions.”
At the time of the revelation, which was exclusively reported by The P&J, the COPFS confirmed it is not responsible for any evidence – also known as Crown productions, becoming “unavailable”.
The sheriff principal went on: “Eventually the Crown sent me a pen drive only to find that it did not open.
“I required the assistance of the technology experts within the Scottish Courts and Tribunals Service to resolve it, by which time three weeks of preparation time had been lost.
“I was then on previously arranged leave abroad for three weeks.”
However, on the senior legal figure’s return from his holiday overseas, in the end, it took just three weeks in total to produce the determination – 3,603 days since Warren Fenty died alone and unnoticed.
Timeline of inquiry:
- June 29 2014: Warren Fenty is discovered dead in a cell at Kittybrewster police station’s brand-new custody suite.
- March 2020: The First Notice from the Crown intimating this matter was received at the Court.
- May 2021: Preliminary hearing in the FAI into the death of Warren Fenty.
- September 2021: Fatal Accident Inquiry begins.
- February 2022: Evidence to the inquiry concludes.
- May 2022: Hearing to discuss the final submissions to the sheriff.
- January 2023: Scottish Courts and Tribunals Service tells The Press and Journal “the determination in this case is due to be published at the end of this month”.
- August 2023: Warren Fenty fatal accident inquiry becomes Scotland’s longest ongoing FAI
- January 4 2024: SCTS aborts another planned publication of the determination less than 24 hours before it was due to finally be made public – without telling Warren’s mum Sharon.
- January 12 2024: Original presiding Sheriff Morag McLaughlin is removed from the inquiry after failing to meet four publication deadlines set by the SCTS.
- January 29 2024: Sharon Fenty attends a showdown private meeting with Sheriff Principal Derek Pyle, who replaced Sheriff McLaughlin, to receive an apology and promise of a report within four weeks.
- February 27 2024: Emergency hearing held to decide the future of the FAI, with Sheriff Principal Pyle rejecting calls to stand down over over some lawyers’ claims that his closed meeting with Mrs Fenty had ignored the principles of open justice.
- March 25 2024: Missing evidence further delays publication of the already extremely overdue report, along with IT issues accessing a memory stick with replacement evidence and the sheriff principal preparing to go on holiday abroad for three weeks.
- May 10 2024: The fatal accident inquiry into Warren Fenty’s death publishes its determination 3,603 days after Warren Fenty died alone and unnoticed.
READ MORE:
Police criticised as sheriff rules Aberdeen man’s death in custody ‘likely’ avoidable
Aberdeen mum claims son’s police custody death inquiry fails to deliver closure or justice
Comment – Justice system guilty of making Warren Fenty’s mother suffer for a decade
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