Police Scotland 'Organisational Failure' says M9 crash inquiry report
The Fatal Accident Inquiry report into the deaths of Lamara Bell and John Yuill is out
An inquiry's found a woman endured "almost incomprehensible" suffering for three days because an 'organisational failure' in call handling by Police Scotland meant she lay injured beside her dead boyfriend following a car crash.
Lamara Bell, who was 25, and 28-year-old John Yuill died after their vehicle left the M9 near Stirling in July 2015.
A Fatal Accident Inquiry has found "organisational failure" in call handling by Police Scotland meant they weren't found - despite officers previously being alerted.
The inquiry also found a police officer who failed to log a call reporting the incident was inadequately trained.
Return from camping trip
Lamara Bell, 25, and John Yuill, 28, died after the car they were in left the M9 near Stirling on July 5, 2015 as they drove back from a camping trip.
They lay in their Renault Clio for three days before being discovered on July 8, despite police previously being alerted to the incident.
Mr Yuill, a father-of-five, was pronounced dead at the scene and Ms Bell, a mother-of-two, died four days later in hospital.
In his determination published following a fatal accident inquiry (FAI) into the incident, Sheriff James Williamson said there was no system of reconciling information recorded by officers in notebooks with action taken.
He said: "The failure of Police Scotland to properly risk assess the call handling procedures and have a system of reconciliation was an organisational failure.
"An organisational failure which led to the safety of the public being compromised and to the events of July 5, 2015."
Police apology
Police Scotland repeated their apology to the families of Mr Yuill and Ms Bell and said that "significant improvements" have been made to call handling systems since 2015, which are now "incomparable" to the systems in place at that time.
The inquiry heard Mr Yuill suffered unsurvivable injuries in the crash but Ms Bell would probably have survived if she had received medical treatment on July 5, albeit with a long-term neurological deficit.
In his determination, Sheriff Williamson noted the Bilston Glen police call handling centre was under pressure that summer amid staffing shortages, and there was confusion among some officers about the tripartite call handling system comprising the Aspire, Avaya and Storm systems.
Police sergeant Brian Henry, now retired, volunteered to do overtime at Bilston Glen, arriving into what the sheriff described as a "confused, fractious working environment".
The inquiry heard that on July 5 he took a call from farmer John Wilson reporting a car off the road and recorded it in his police notebook, but he failed to log it into the Storm case management system and no action was taken.
Sheriff Williamson found police had not identified the risk that calls might not be dealt with.
He said: "Brian Henry was inadequately trained and left largely unsupervised to operate a system that allowed for human error to go undetected.
"His human error going undetected meant that Lamara Bell was left in a vehicle by the side of a major motorway in Scotland suffering devastating injures.
"These injuries, together with the delay in rescuing and treating her, led to her death."
The crashed car was discovered on July 8, 2015 after another member of the public rang police to report seeing it and emergency services went to investigate.
Multiple failures
Sheriff Williamson found the incident was not the result of one individual failure by Police Scotland but "more than one and these failures took place over a lengthy period of time, during which the opportunity to resolve them was lost".
The FAI came after the family of Ms Bell was awarded more than ÂŁ1 million in damages from Police Scotland in a civil settlement in December 2021.
In September 2021, the force was fined ÂŁ100,000 at the High Court in Edinburgh after it pleaded guilty to health and safety failings which "materially contributed" to Ms Bell's death.
Sheriff Williamson said Ms Bell's suffering over a period of three days, when she was severely injured but conscious, is "almost incomprehensible".
He said that since the incident in 2015, the police Contact, Command and Control Division (C3 Division) has been transformed into an "efficient, tightly-controlled and sophisticated complex of service centres all capable of communicating with each other on a unified IT network" that is better able to serve and protect the public than in 2015.
He said: "It is not risk-free. It still has a susceptibility to human failure, but the risk of human failure and that failure going undetected is now marginal."
"Deaths a tragedy"
Deputy Chief Constable Alan Speirs said: "Lamara Bell and John Yuill's deaths were a tragedy and my first thoughts today are with their family and friends.
"Police Scotland failed Lamara and John in 2015 and I repeat the personal apology made previously to their loved ones. We did not keep them safe in their time of need as was our duty and for that I am truly sorry.
"We have fully participated with all inspections, investigations and inquiries established since July 2015 to identify what went wrong and to do everything we possibly can to stop a terrible incident such as this being repeated.
"Sheriff Williamson's findings highlight the significant improvements which have been made to our call handling systems. How we respond to 999 and 101 calls now is incomparable to how we dealt with them in 2015.
"None of these provide consolation to Lamara and John's loved ones, but I can give them my assurance that lessons have been learned and that the relentless improvement of service delivery lies at the heart of everything we do.
"We are studying the determination in detail for any learning which will form part of this continuous improvement."