Police blamed after human error caused M9 tragedy

An “organisational failure” in the police’s call handling system that failed to detect human error by call handlers left a woman injured three days in her car on the side of a motorway, a fatal accident inquiry (FAI) has found.

Lamara Bell’s injuries, along with the delay in rescuing and treating her, led to her death, the sheriff leading the investigation said.

They said the driver of the car, John Yuill, died from head and stomach injuries in a crash on the M9 near Stirling in July 2015.

However, Ms Bell’s injuries may have been spared if she had been rescued after a call was made to Police Scotland later that day, he said.

The sheriff’s FAI report said Police Scotland had failed to properly assess risk in call handling procedures and had no system in place to check calls.

He said it was an organizational failure that led to public safety being compromised and had “fatal consequences” for 25-year-old Ms Bell.

Sheriff James Williamson hit out at criticism of Police Scotland and said the man who failed to log the call was not trained and supervised to operate a system that allowed human error to go undetected.

He said the circumstances of the death had a corrosive effect on public confidence in Police Scotland.

However, the report made no recommendations for future action, saying Police Scotland had learned from the tragedy and changed procedures over the past nine years.

The sheriff’s report said the couple, both from Falkirk, had been on a camping trip at Loch Earn and left in the early hours of Sunday 5 July.

Mr Yuill – who only had a provisional license – was driving and had taken cannabis and consumed alcohol for several hours before leaving.

The car went down the embankment some time between 06:00 and 06:15, after crossing the hard shoulder and kerb.

Mr Yuill, 28, died of his injuries but Ms Bell survived.

Later that morning – at around 11.30am – farmer John Wilson saw a car crash under an embankment and called the police on the non-emergency 101 number.

He assumed the police would take action but the call never made it into the system.

The next day, Mr. Wilson saw that the car was still there.

On the morning of Wednesday July 8 another farmer saw the car and went down the embankment to investigate.

Mr. Yuill was dead but he could hear Ms. Bell calling for help.

He was taken to hospital but died four days later.

The FAI report said that if Ms Bell had been admitted to hospital on the day of the accident her head could have been managed and complications such as brain swelling, hypothermia and systemic infection could have been avoided.

They said he would survive but would have long-term neurological deficits.

In the initial call to report a car down an embankment, Mr Wilson spoke to Brian Henry, a police sergeant who had volunteered to work overtime to help at the Bilston Glen contact centre, which the sheriff described as a “confused and fragmented work environment.”.

The report said Mr Henry gave evidence to the inquiry and “does not shrink from the fact that he took the phone and failed to act”.

It said Mr Henry offered his “heartfelt and sincere apologies” to his family and had been tormented in the years since the accident trying to understand what had happened and provide an explanation for him.

“In the end they couldn’t do it, beyond simple human error,” the report said.

The FAI’s determination Sheriff Williamson said Mr Henry had not deliberately ignored the call and appreciated that it had to be done.

He made a handwritten note in the “Pot Book” but thought that while checking to see if the incident had been recorded, he was interrupted.

Mr. Henry attended another call for the remainder of his shift and never returned to check the entries in his notebook.

The report said that the system, which does not check incoming calls against outgoing actions, means there is a risk of human error going undetected.

It said Police Scotland can ensure all call handlers – even non-core staff like Mr Henry – are trained to use the Aspire system at all times.

Police Scotland admits it failed to train Brian Henry and other non-core call handlers.

The report said the failure of the force led to a situation where mistakes such as those committed by Mr Henry could have been made.

The Sheriff said Police Scotland is a very different organization today than it was in 2015.

He said the force and other experts were confident the type of mistakes that led to the deaths of Mr Yuill and Ms Bell would be repeated.

“It goes so far that just deliberately ignoring the call will result in the call not being made,” he said.

Police Scotland has previously admitted criminal liability and pleaded guilty to violating the Health and Safety at Work Act that the failure to record and act on the call led to Ms Bell’s death and was fined £100,000.

Deputy Chief Constable Alan Speirs repeated his apologies to the family and said the police had done everything they could to stop such horrific incidents from happening again.

“Sheriff Williamson’s findings highlight the significant improvements that have been made to our call handling system,” he said.

“The way we respond to 999 and 101 calls today cannot be compared to the way we handled them in 2015.”

He added: “We are determined to learn in detail any study that will be part of this continuous improvement.”

John Yuill’s father, Gordon, said he accepted the accident was his son’s fault, but he would hate to see anyone go through the ordeal his family and Ms Bell have endured over the past nine years.

“We tried to grieve for my son and it wasn’t allowed,” she said.

“That was taken from us.”

Mr Yuill said problems with sickness rates and staff shortages at Police Scotland’s Bilston Glen call center had been known before the incident.

“I don’t blame the officers. I don’t believe they were properly trained to work with the system,” he said.

“Without training, accidents are bound to happen. It should be built into the system so that human error cannot happen.”

Mr Yuill said he was disappointed the report did not make recommendations to ensure the same mistake could not happen again.

Andy Shanks, who leads the death investigation for the Crown Office and Procurator Fiscal Service (COPFS), said: “We know that the time it takes for the investigation and the criminal process to finish and start the investigation must be very difficult for the families of Lamara Bell and John Yuill.”

He noted that it was a complex case and said that the way deaths are investigated has changed in recent years to reduce delays.

Shanks added: “The procurator fiscal will continue to liaise with the family following the conclusion of this complex and lengthy FAI and answer any questions about the determination.”