Sheriff concludes defects in police procedure contributed to death of woman set on fire by mentally ill ex-partner

About this case:

• Citation:
  [2024] FAI 13
• Judgment:
  External link
• Court:
  Sheriff Court
• Judge:
  Sheriff G L Hammond

Ann Drummond, 47, died on 27 June 2019 as a result of extensive burns inflicted by Kevin Marks, who was not criminally responsible for his conduct due to mental disorder. The Crown accepted a not guilty plea by Mr Marks and he was detained at the State Hospital in Carstairs.

The inquiry was conducted by Sheriff Peter Hammond at Livingston Sheriff Court. Ms Sun, procurator fiscal depute, represented the Crown. Ms Bennett, counsel, represented NHS Lothian Health Board, and Ms Toner, counsel, represented Police Scotland. The family of Ms Drummond were not legally represented and attend solely as observers.

Should have engaged

Until one week prior to her death, Ms Drummond had been in a relationship with Mr Marks. They had lived together until 19 June 2019, when he moved out following the breakdown of the relationship. Mr Marks had a history consistent with alcohol and drug dependence syndrome, and in 2015 was assessed as not having any psychiatric disorder.

It was noted that Mr Marks had had a number of contacts with Police Scotland and NHS Lothian in the lead up to the assault which led to Ms Drummond’s death. Despite these interactions, his presentation was not noted by NHS Lothian as psychotic, and he was not considered to be a risk to himself or others. He had previously been warned by police about his behaviour towards former partners and in one case convicted of a breach of the peace with a domestic aggravator.

On 20 June 2019, Mr Marks phoned 999 to report allegations that the deceased and another male had sexually assaulted him. In a call, he was recorded as saying he wanted to put a knife right under the deceased’s chin. On 25 June 2019 he appeared at Livingston Sheriff Court for an unrelated offence and was picked up from court by the deceased. Shortly after, on a country road near Bathgate, Mr Marks set the deceased on fire.

It was submitted by the Crown that the communication between NHS Lothian and Police Scotland in the leading up to the offence was poor and that the police should have engaged with the deceased following their repeated interactions with Mr Marks between 20 and 24 June 2019. It was noted in evidence that Police Scotland had since reviewed their procedures and introduced new contact programmes to improve standards of service for response to vulnerability, risk, and public need.

Worrying bigger picture

In his determination, Sheriff Hammond said of the witnesses: “Generally, I found all the witnesses to the Inquiry to be credible and reliable. There was little, if any, dispute about the facts spoken to in evidence. The controversy was rather about the inferences which could be drawn from those facts; and in particular the thoroughness and appropriateness of the various agencies’ and witnesses’ responses to their interactions with Mr Marks and Ms Drummond.”

Addressing the specific submissions made by NHS Lothian and Police Scotland, he noted: “The submissions of both Police Scotland and NHS Lothian understandably tended to focus on justifying their own organisation’s involvement. The approach was to look at each stage of involvement to argue that findings suggesting fault should not be made having regard to the state of knowledge of those concerned at the material time and their adherence to procedures. The problem with that approach is that it fails to acknowledge the larger picture.”

He explained further: “A man with a previous psychiatric history, exhibiting psychotic symptoms and hostility towards the deceased and with an, albeit limited, domestic history had repeated contacts with police and NHS services in the days before the fatal act, and yet his condition and the risks that it posed to him and others was not recognised or acted on. Individual pieces of information were processed, passed on and retained separately, without being drawn together so that decision makers in the police and NHS were alerted to the development of a worrying bigger picture of risk.”

Sheriff Hammond concluded: “The effective sharing of potentially relevant information held by the police, within the police service itself and with NHS staff, about the mental health of Mr Marks, based on recent contacts with him, might have led to the detection of his psychosis and the taking of protective steps. As such, that was a precaution which could reasonably have been taken, which might realistically have resulted in the death of Ms Drummond being avoided.”

Having considered the changes in Police Scotland’s operating procedure made since June 2019, the sheriff chose to make no recommendations.