Parliament Workbench
Data: Official Report to 12 Nov 2026

Official Report · Committee

Continued Petitions

Human Tissue (Scotland) Act 2006 (Post Mortems) (PE1911)

Wednesday 29 May 2024 Citizen Participation and Public Petitions Committee About 10:30–10:45 Petitions 8 contributions · 3 speakers

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The record

8 contributions
Jackson Carlaw Con The Convener · Eastwood
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Our next continued petition, PE1911, was lodged by Ann Stark, who I think I can see with us in the gallery again. I say, “I think,” because I have a big spotlight shining in my face and it is difficult to see anybody down at that end of the room from here. The petition calls on the Scottish Parliament to urge the Scottish Government to review the Human Tissue (Scotland) Act 2006 and the relevant guidance to ensure that all post mortems can be carried out only with the permission of the next of kin; that brains are not routinely removed; and that tissues and samples are offered to the next of kin as a matter of course.

We are again joined by our colleague Monica Lennon, who has been with us before when we have considered the petition. Good morning and welcome, Monica.

We last considered the petition on 6 September 2023. At that time, we agreed to write to the Crown Office and Procurator Fiscal Service, the Royal College of Pathologists and other relevant organisations. The response from COPFS to the committee confirms that recent discussions with pathology providers have included the benefits of and possible difficulties with the suggestion to use CT scanners as an alternative to invasive post-mortem examinations. The response also highlights the HM Inspectorate of Prosecution in Scotland’s annual report for 2022-23. The inspector’s view is that consideration of the delivery model for forensic pathology is required. The report notes the cross-sector nature of work in the area and therefore suggests that the Scottish Government should lead on it.

Both the Royal College of Radiologists and the Royal College of Pathologists have highlighted the existing clinical guidelines relating to the use of CT scans in post-mortem examinations. The Royal College of Radiologists states that there should in principle be no reason why CT scans could not be used during post-mortem examinations in Scotland, and that the guidance notes that, at the time of writing, the availability of expertise in imaging interpretation was limited to a small number of centres in the UK.

The Royal College of Pathologists notes that many types of deaths that can be diagnosed by post-mortem imaging in England would not require an autopsy in Scotland. The submission suggests that the impact of scanning on the overall autopsy rate in Scotland is likely to be much less than in England.

The petitioner has provided two written submissions, which reiterate the key ask of her petition. She also notes that a meeting recently took place between her and the Lord Advocate—I think that Monica Lennon may have been at that meeting, too—in which they discussed her individual case and the changes that she wishes to see.

The committee has uncovered a number of issues throughout its consideration of the petition. We have gathered a lot of written evidence from a number of key organisations and have taken oral evidence to inform our thinking of the issues, all of which have had us as passengers in support of the aims of the petition as it progresses the issue. Before I invite committee members to suggest where we might go next, I invite Monica Lennon to give a brief statement.

10:45

Monica Lennon Lab Central Scotland
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Good morning, convener, and thank you for your opening remarks. Having listened to your recap, I note that we have been on quite a journey. I pay tribute to Ann Stark and her husband, Gerry, as well as the committee. At the start of the process, we knew very little about the Parliament’s understanding of what was going on. The Government was not taking an active interest and, it is fair to say, the Crown Office and Procurator Fiscal Service thought that there was nothing to see.

The convener mentioned the meeting on 17 April with the Lord Advocate and Andy Shanks, who is the head of the Scottish fatalities investigation unit. I was present along with Ann Stark and Gerry Stark. The meeting lasted for almost two and a half hours. The Lord Advocate was very much in listening mode, but she had lots of questions, which speaks to the fact that, since Richard Stark’s death in 2019, the family have been trying to get answers. That shows how difficult it can be for grieving families to deal with the system. The petition has always been about improving the system, not just for the Stark family but for all families in Scotland.

I extend my thanks to the committee, because a lot of evidence and information is now available to us. We know that we need to learn lessons, but we also need to learn from other jurisdictions where families have been listened to and where the process of modernisation has been started, if not rolled out. Lessons have been learned in relation to the process, including about making efficiencies and savings at a time when public finance is under pressure, but the changes have also led to a more compassionate experience for families. On behalf of Ann Stark and Gerry Stark, I emphasise that the petition is about trying to minimise distress for grieving families at the worst time in their lives. As Ann has said in her written submissions, Richard’s death was not suspicious, but the family feel that they were treated in exactly the same way as they would have been were it a murder case or a highly suspicious death. That made their ordeal all the harder to bear.

I will touch on the discussions that we had with the Lord Advocate. I characterised her evidence session with the committee as tense, because it was quite difficult to try to tease out who was going to take responsibility for making change happen. The Lord Advocate has written to us since that meeting, making it clear that she shares the family’s desire for COPFS to make whatever improvements it possibly can. She reiterated her apology for the poor communication on behalf of the service and recognised that that caused unnecessary distress. There was some discussion about the family liaison charter, which should include looking at the medical history of the deceased and would inform whether a full invasive post mortem is required. We recognise, not just for the Stark family but for many families, that there is a communication issue, which is something that COPFS is looking at.

We know that COPFS is committed to the continuous improvement of its death investigation work. It is fair to say that it is as a result of the petition and the committee’s work that an improvement programme in the system for the investigation of deaths has been established. The purpose is to oversee a programme of work that is designed to achieve greater public confidence—which is really important—improve the service, deliver to bereaved relatives and deliver increased efficiencies in the investigation of deaths.

On the issue of samples, which I know is covered in the committee’s briefing papers, I want to reiterate that Richard Stark died in 2019. As we sit here today, on 28 May 2024, his parents and wider family still await confirmation that all of Richard’s body samples are accounted for. The Lord Advocate has confirmed in her letter to me that she is making further inquiries with pathology providers that are contracted to do that work. Again, that shows how difficult this can be.

As you have been told, COPFS regularly meets the current pathology providers, and the potential future use of CT scanners has, from time to time, formed part of their discussions. It is our view—it is my view from speaking to the family—that the conversations have not led to anything up until now and that that has been mentioned almost in an ad hoc way.

However, more positively, since the Lord Advocate last appeared at the committee, members of COPFS’s pathology, toxicology and mortuary programme board visited Northern Ireland. They received a presentation, which we are told was informative, from the state pathologist on the experience in Northern Ireland of utilising CT scanning. We welcome that.

Mrs Stark and the family suggested to the Lord Advocate that COPFS staff or members of its pathology, toxicology and mortuary programme board should perhaps visit Lancashire, where we believe that Dr James Adeley would be happy to facilitate a fact-finding trip. I know that, from time to time, the committee gets out of Parliament, and my suggestion to the committee is that it might wish to consider the opportunity for such a site visit. If the Lord Advocate and her colleagues are considering that, it would be worth checking where they have got to.

I will not repeat points that have been made about the resourcing issues and the workforce pressures that are facing COPFS and, more generally, pathology and other health services that are involved. It is very much a case of our needing to have the right people doing the right jobs. We have identified that there are shortcomings in the skill set in COPFS. That is why, in a paper that he submitted to the UK Justice Committee back in September 2020, Dr Adeley talked a lot about the importance of communication and the relationship with families. I have that submission in front of me. We want to minimise stress, deal with workforce pressures and use public resources better. We have heard about potential savings and at least achieving cost neutrality through the work in Lancashire.

I want to thank the committee, because we can see that your work is making a difference. We still have quite a distance to go, and, right now, I am not so confident about how engaged the Scottish Government is or about how meaningful that engagement is. Therefore, I think that the visit would be important. The opportunity here is to minimise the stress to grieving families, modernise the investigation of unexpected and sudden deaths and build resilience into the system. The scanners give us another tool that we do not currently have. The Human Tissue (Scotland) Act 2006 needs reform.

Today, I am giving only one example: the Stark family’s situation. However, as you know from Ann Stark’s submissions, many other families have found themselves in that situation. I thank the committee for its compassion for the Stark family, but we want every family to experience the same level of compassion and for the system to be modernised. Thank you.

Jackson Carlaw Con The Convener · Eastwood
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Thank you very much for that, Monica Lennon.

We have now assembled a considerable amount of evidence. Having had a chance to discuss these matters privately as well, the committee is of the view that we now need to write to the Scottish Government directly highlighting some of the matters that we have raised.

I wonder whether one of my colleagues would like to summarise, for the record, what areas we are proposing that that letter would cover.

Fergus Ewing SNP Inverness and Nairn
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There is a lot of ground to cover, so I will just read the text from our briefing paper.

Jackson Carlaw Con The Convener · Eastwood
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Yes, it is a comprehensive series of asks.

Fergus Ewing SNP Inverness and Nairn
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It is. I am very grateful for Monica Lennon’s work in taking up this matter so diligently, which is a credit to her. We should write to the Scottish Government to highlight the HM chief inspector of prosecution’s view that consideration of the delivery model for forensic pathology is required, and that the Scottish Government should lead that work. In passing, I note that it was evident that the Crown Office and the Lord Advocate passed the buck in their evidence by saying that it is primarily a matter of medical evidence. They were, if you like, not taking the lead, so the Scottish Government should take the lead in that regard.

In addition, we should highlight the issues and suggested improvements to pathology services that were raised during the committee’s consideration of the petition, including the lack of clear direction and fragmented nature of the service, which is leading to challenges in resolving issues as they arise and the inconsistent and unclear communication with the next of kin, as well as the suggestions that tissue samples are returned to the next of kin and that CT scanners are used as an alternative to invasive post mortems. Thanks to the petitioners, Monica Lennon and the committee’s work, we have had a lot of evidence about each of those issues, so there is no point in rehearsing all that.

We should also highlight concerns in forensic pathology services about value for money, affordability, sustainability and contractual terms, as noted in the HM Inspectorate of Prosecution in Scotland’s annual report. We should highlight COPFS’s call for a national forensic pathology service.

We should recommend that the Scottish Government brings together service providers, the Crown Office and stakeholders to consider the key challenges that face pathology services as identified in the petition and the inspectorate’s report, takes ownership of and leads the development of a delivery model for pathology services, and ensures that any delivery model facilitates continuous and long-term improvement of pathology services.

In conclusion, that is all a bit dry—it is MSP-speak—but at its heart is the concern that the next of kin’s wishes should be respected and taken into account, and that they should be treated with dignity and respect in the desperately difficult situation that they face.

Jackson Carlaw Con The Convener · Eastwood
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Thank you, Mr Ewing. That obviously draws on a lot of what the committee has heard. In the first instance, I think that we should set that out to the Government in the terms that Mr Ewing has suggested, and see what response we get, which would then inform how we might take forward the matter. Do members agree with that proposal?

Members indicated agreement.

Jackson Carlaw Con The Convener · Eastwood
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We will keep open the petition and act on that basis. I thank members and the petitioners for the work that has been done.

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