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Call for review of weekend staffing at maternity unit after death of newborn
Call for review of weekend staffing at maternity unit after death of newborn

STV News

time5 days ago

  • Health
  • STV News

Call for review of weekend staffing at maternity unit after death of newborn

A Fatal Accident Inquiry (FAI) has told a health board to review its weekend and evening staff following the death of a newborn baby in 2018. Freya Murphy was born on July 21 2018 at 9.31am in Queen Elizabeth University Hospital (QUEH) in Glasgow and died there on July 28, aged seven days and 12 hours old. The cause of death was given as global ischemic brain injury associated with acute chorioamnionitis. An inquiry was held into the death where Freya's parents questioned why the UK is not screening pregnant mothers for Group B strep, and they raised concerns about 'failings in her care' at the QEUH. First-time mother Karen Murphy and her husband, Martin Murphy, said they have been 'left devastated by failings in her care' and 'missed a lifetime of memories with our precious daughter', while their other children 'suffer daily without their big sister'. Sheriff Barry Divers said that there were 'no defects in any system of working which contributed to Freya's death' and said the death 'could not realistically have been avoided'. He, however, found a 'clear impression from the evidence' that if Freya's difficult birth had occurred on a Monday rather than a Saturday, the hospital's 'inability to open a second theatre would have been one less issue to worry about'. 'It does seem to me on the basis of the evidence I heard, that if an emergency of this type arises, with two patients both of whom need to be in theatre at the same time, then QEUH is far better able to cope with that demand during a weekday than at the weekend,' Sheriff Divers said in his determination. 'As such emergencies can arise at any time, it seems to me that such a situation might amount to a defect in the system of work.' The sheriff also made a recommendation in relation to UK policy on screening for Group B Streptococcus ('GBS'). Mrs Murphy, then aged 32 and a first-time mother, was deemed to be a 'low-risk' pregnancy, and induction was planned for July 20 2018, however, she requested it be pushed back by three days, according to a statement of agreed evidence read to the court. Fiscal depute Amanda Allan told the court that on July 19, Freya's heartbeat was recorded as 150 beats per minute (bpm), and Mrs Murphy, a teacher from Cambuslang, began contractions later that day. The following evening, Mrs Murphy arrived at the QEUH with the foetal heartbeat noted as 144bpm and she was transferred to the labour unit at about 10.20pm. At 6.30am on July 21, she was advised to start pushing, the inquiry heard. At about 7.20am, a midwife noted that Mrs Murphy's pulse was elevated, and informed Dr Felicity Watson, who had carried out a vaginal examination and advised Mrs Murphy that she could have a 'rest from pushing for an hour', which she declined to do, Ms Allan told the court. Midwife Helen Kidd reported at 8.45am that a CTG (cardiotocograph) was showing signs of 'deceleration', however, Dr Amy Sinclair and Dr Marieanne Ledingham left to attend another woman, Patient A, the court heard. At the time, 12 women were on the ward, including seven in labour. Dr Ledingham returned to review Mrs Murphy and noted 'deceleration', however, Dr Sinclair advised her that Patient A needed surgical delivery. The court heard that Dr Sinclair and Ms Kidd delivered baby Freya at 9.30am 'covered in copious thick meconium'. Ms Allan said: 'Freya was noted to be born in poor condition, she required resuscitation and CPR continued for 17 minutes.' Freya was then transferred to neonatal ICU and was suspected to have suffered a brain injury, the inquiry heard. Ms Allan added: 'It was agreed that continuing intensive care treatment was not in Freya's best interests and she was unlikely to survive.' Freya died just before 10pm on July 28, aged a week old, and her cause of death was global hypoxic ischaemic brain injury associated with acute chorioamnionitis, following a post-mortem examination. A significant clinical incident investigation review was carried out in 2019 with six recommendations, and an external review was commissioned by Dr Michael Munro, a neonatal specialist who wrote in a report that 'amnionitis caused by Group B strep remains the most likely cause of Freya's brain injury as there appears to be nothing else to cause it', and noted that after birth, 'care was delivered to (a) high standard', the court heard. Giving evidence by videolink, Dr Munro said: 'The trajectory of the decline is really impossible to be certain of, there are no studies I'm aware of, of the specific circumstances Freya found herself in. 'The process of that starting and the baby dying can be just less than 30 minutes.' Dr Munro said he believed Group B strep – an infection passed from the mother's body to the baby via amniotic fluid – was 'the most likely cause as there's nothing else from the notes I've seen to explain what happened'. He said: 'It can cause stillbirth, therefore, what we are dealing with here is stillbirth just before Freya's heart tragically stopped.' He agreed that earlier delivery would have helped, but added: 'I don't think it's possible to say, 'had Freya been delivered at this time point she would have avoided brain injury or survived'.' Dr Munro told the court the mortality rate (of Group B strep) is 'round about 5%, it's a minority of babies who succumb' and Freya was 'close to being recorded as (a) stillbirth' as her heartrate was so slow. He added: 'A lot of women carry Group B strep, around a third – it singles out a very small number of babies, either causing a stillbirth or a baby to be born in very poor condition.' Dr Munro said screening for Group B strep has been carried out in America since 2002, and 15,000 babies born in Scotland in 2023 would have been potentially affected by the infection. He said the 'risk of exposing lots of babies to antibiotics they don't need' was a major consideration for medics, but added: 'I would like universal screening. One of the most advanced healthcare systems in the world is doing it and you have to question why the UK is not.' The determination said: 'It was clear on the evidence that all those clinicians (doctors and midwives) who spoke to their involvement with Freya, were motivated in their actions by doing what they thought was best for Freya and Mrs Murphy. 'It was obvious during their evidence that Freya's tragic death has left a mark upon each of them in different ways which will last for the rest of their professional careers and beyond. 'For the reasons I have explained, I have not been able to make all the findings or recommendations which they sought. 'However, I hope that the entirety of this FAI process, including the preparation for the evidential hearing, the evidence which was led, the submissions made and this determination, has at least addressed the questions which they have about what happened. 'It was suggested that the adoption of routine screening for GBS would be a suitable tribute for Freya. I understand why that submission was made. 'However, if I might respectfully say, I do not consider that would be accurate, even if it were to happen. 'The real tribute to Freya is the obvious love carried for Freya by her mother and father, which love has no doubt been passed on to Freya's siblings.' Dr Claire Harrow, deputy medical director for acute services at NHS Greater Glasgow and Clyde said: 'We would like to extend our sincerest condolences to the family of Freya Murphy, and once again to apologise for the distress they have experienced. 'The care Freya received fell below the standards expected and for this, we are very sorry. 'We have received the findings from the FAI. The recommendation for NHSGGC on staffing has already been implemented. 'In line with the recommendation on Group B Streptococcus, we plan to make a formal approach to United Kingdom National Screening Committee.' Get all the latest news from around the country Follow STV News Scan the QR code on your mobile device for all the latest news from around the country

Prison officers 'failed to check in' on inmate who took own life at Polmont YOI
Prison officers 'failed to check in' on inmate who took own life at Polmont YOI

Daily Record

time20-05-2025

  • Daily Record

Prison officers 'failed to check in' on inmate who took own life at Polmont YOI

Prison officers failed to properly check up on an inmate who had taken his own life in prison, a probe has found. Jack McKenzie was pronounced dead in his cell at Polmont Young Offenders Institute (YOI) just before 8am on September 1, 2021, 90 minutes after guards were meant to conduct a thorough 'hatch check' on his wellbeing. A Fatal Accident Inquiry (FAI) also found the Scottish Prison Service (SPS) 'condoned' the incident by not disciplining staff involved. McKenzie had been at the institution for nine months on rape and sexual assault charges, which he denied. Sheriff Simon Collins ruled his death as 'unpredictable' but criticised the prison service for 'poor practice'. The 20-year-old from Shettleston, Glasgow, had been confined to his cell following an 'aggressive' outburst attributed to drugs on September 1 and his death could have occurred between 3am and 7.36am that night, the inquiry found. The SPS has since apologised to Jack's family for the failings found in the report and his sad death. The young man, who lost both parents to drugs, was described as a 'chronic drug user' who had been remanded four times in three years in Polmont. However his death was described as 'impulsive' and a report called for improvements to cell environments. Sheriff Collins - who presided over the Katie Allan and William Brown FAI, which also probed the prison - said 10 young prisoners died by suicide there between 2010 and 2023, while more than 120 prisoners died by suicide in Scottish prisons between 2011 and July 2024. A total of seven recommendations were made, with the report saying: 'Jack's death was spontaneous, unpredicted and unpredictable. But it is well known that prisoner suicides can be so. 'Accordingly prisoners should, insofar as reasonably possible, be detained in environments which are safe, in the sense of minimising the risk of such suicides.' The report said an audit had been done of potential suicide risks in equivalent cells and using the Manchester Tool Kit (MTK), Mr McKenzie's cell would have 'indicated the highest level of risk'. It said: 'If a young, vulnerable prisoner was accommodated, without regular observation, the resulting overall MTK scoring for the cell would have indicated the highest level of risk, calling for remediation.' The sheriff wrote it 'would have been a reasonable precaution for the Scottish Prison Service prior to September 2021, to have removed and replaced the toilet cubicle door in Jack's cell, or to have modified it, such that it was not readily capable of being used… without significant ingenuity or adaptation'. A six-month deadline was set for SPS to reduce 'abusive and bullying verbal behaviour, drug dealing, and to respond to physical disturbances' during the night, in the sheriff's determination. Mr McKenzie was perceived by staff as 'jovial, funny, likeable and talkative' but on drugs could be 'aggressive, agitated and anti-authority' and traded substances. However, he had never been assessed as suicidal, the report added. On September 1, Mr McKenzie smashed two phones and was restrained and confined to his cell due to becoming 'non-compliant' and intoxicated – using an order which would have expired on September 4 just after 3pm. The report said: 'There was simply nothing to indicate, prior to September 3 2021, that Jack had any thoughts or intention of dying by suicide'. Accounts from neighbouring cellmates suggested 'Jack was still alive at around 3am to 4am' on September 3, the report said. Then at 6.37am on September 3, two prison officers failed to carry out a hatch check at Mr McKenzie's cell to ensure he was safe and failed to take steps to ascertain his whereabouts, and did not log concerns on a handover, it added. A recommendation said: 'A sanction should have been imposed on both officers and/or corrective training required of them.' Governor Gerry Michie did not issue any 'disciplinary action, reprimand, warning or sanction' and neither officer was 'offered, nor required, to undertake additional training '- which was branded 'unacceptable' in the report. It said: 'The absence of any disciplinary action, given the seriousness of the breach, and the possible seriousness of the consequences of it, is incongruous and unacceptable. 'I do not accept, as SPS submitted, that this was within the range of reasonable responses open to governor Michie. 'Rather, it was a response which sends a message to prison officers that they will not be held to account for a failure to 'do the basics well', and a message to the public that the first response of SPS to poor staff practice in the context of the death of a prisoner is to close ranks and protect its own.' Join the Daily Record WhatsApp community! Get the latest news sent straight to your messages by joining our WhatsApp community today. You'll receive daily updates on breaking news as well as the top headlines across Scotland. No one will be able to see who is signed up and no one can send messages except the Daily Record team. All you have to do is click here if you're on mobile, select 'Join Community' and you're in! If you're on a desktop, simply scan the QR code above with your phone and click 'Join Community'. We also treat our community members to special offers, promotions, and adverts from us and our partners. If you don't like our community, you can check out any time you like. To leave our community click on the name at the top of your screen and choose 'exit group'. If you're curious, you can read our Privacy Notice. Procurator fiscal Andy Shanks said: 'The sheriff's determination, which makes significant recommendations in relation to reduction and prevention and the checking of cells, is extensive and detailed. 'The FAI followed a thorough and comprehensive investigation by the procurator fiscal who ensured that the full facts of Jack's death were presented in evidence. My thoughts remain with Jack's loved ones.' An SPS spokesperson said: 'We would like to offer our sincere condolences and apologies to the family of Jack McKenzie for his sad death and the failings identified in this report. 'We are grateful to Sheriff Collins for his recommendations, which we will fully consider as we continue to deliver systemic change, at pace, in a way which keeps young people in our care safe, during one of the most challenging and vulnerable periods of their lives.'

Prison ‘closed ranks' after young inmate died, FAI finds
Prison ‘closed ranks' after young inmate died, FAI finds

Glasgow Times

time20-05-2025

  • Glasgow Times

Prison ‘closed ranks' after young inmate died, FAI finds

Jack McKenzie, 20, died in his cell at Polmont YOI in September 2021, nine months after being remanded on rape and sexual assault charges, which he denied. Jack was pronounced dead in his cell at 7.57am on September 3, after taking his own life, which was deemed 'unpredictable' in a Fatal Accident Inquiry (FAI) determination by Sheriff Simon Collins, after hearing evidence at Falkirk Sheriff Court. READ MORE: Heartbroken school pays tribute to 'kind and caring' teen after Irvine beach tragedy Jack had been confined to his cell following an 'aggressive' outburst attributed to drugs on September 1. His death could have occurred between 3am and 7.36am, the inquiry found; however, two prison officers tasked with a 'hatch check' just after 6.30am did not do so sufficiently, and a total of seven recommendations were issued to the Scottish Prison Service (SPS) regarding improvements. Sheriff Collins said in his determination: 'Poor practice must be investigated and sanctioned, not ignored and therefore – apparently – condoned." It added: 'The purpose of imposing a sanction is not to criticise prison officers for the sake of it, but to seek to drive up standards in the hope, in the present context, of preventing the deaths of further young prisoners by suicide.' A six-month deadline was set for SPS to reduce 'abusive and bullying verbal behaviour, drug dealing, and to respond to physical disturbances' during the night, in the sheriff's determination. Jack was described as a 'chronic drug user' who had been remanded four times in three years in Polmont YOI, however, his death was described as 'impulsive," and a report called for improvements to cell environments. Sheriff Collins, who presided over the Katie Allan and William Brown FAI, which also investigated Polmont, said 10 young prisoners died by suicide there between 2010 and 2023, while more than 120 prisoners died by suicide in Scottish prisons between 2011 and July 2024. A total of seven recommendations were made, and the report said: 'Jack's death was spontaneous and unpredictable. But it is well known that prisoner suicides can be so. 'Accordingly, prisoners should, insofar as reasonably possible, be detained in environments which are safe, in the sense of minimising the risk of such suicides.' READ MORE: Owners banned after dogs endured 'unnecessary and avoidable suffering' The report said an audit had been done of potential suicide risks in equivalent cells and using the Manchester Tool Kit (MTK), Jack's cell would have 'indicated the highest level of risk." It said: 'If a young, vulnerable prisoner was accommodated, without regular observation, the resulting overall MTK scoring for the cell would have indicated the highest level of risk, calling for remediation.' The sheriff wrote it 'would have been a reasonable precaution for the Scottish Prison Service prior to September 2021, to have removed and replaced the toilet cubicle door in Jack's cell, or to have modified it, such that it was not readily capable of being used… without significant ingenuity or adaptation." Jack was perceived by staff as 'jovial, funny, likeable and talkative' but on drugs could be 'aggressive, agitated and anti-authority' and traded substances. However, he had never been assessed as suicidal, the report added. On September 1, Jack smashed two phones and was restrained and confined to his cell due to becoming 'non-compliant' and intoxicated, using an order which would have expired on September 4 just after 3pm. The report said: 'There was simply nothing to indicate, prior to September 3 2021, that Jack had any thoughts or intention of dying by suicide." Accounts from neighbouring cellmates suggested 'that Jack was still alive at around 3am to 4am' on September 3, the report said. At 6.37am on September 3, two prison officers failed to carry out a hatch check at Mr McKenzie's cell to ensure he was safe and failed to take steps to ascertain his whereabouts, and did not log concerns on a handover, it added. A recommendation said: 'A sanction should have been imposed on both officers and/or corrective training required of them.' Governor Gerry Michie did not issue any 'disciplinary action, reprimand, warning or sanction' and neither officer was 'offered, nor required, to undertake additional training," which was branded 'unacceptable' in the report. The report said: 'The absence of any disciplinary action, given the seriousness of the breach, and the possible seriousness of the consequences of it, is incongruous and unacceptable. 'I do not accept, as SPS submitted, that this was within the range of reasonable responses open to Governor Michie. 'Rather, it was a response which sends a message to prison officers that they will not be held to account for a failure to 'do the basics well', and a message to the public that the first response of SPS to poor staff practice in the context of the death of a prisoner is to close ranks and protect its own.' READ MORE: Glasgow dad 'feels robbed' after losing wife and son to same heart condition Procurator fiscal Andy Shanks said: 'The sheriff's determination, which makes significant recommendations in relation to reduction and prevention and the checking of cells, is extensive and detailed. 'The FAI followed a thorough and comprehensive investigation by the procurator fiscal, who ensured that the full facts of Jack's death were presented in evidence. My thoughts remain with Jack's loved ones.' A Scottish Prison Service spokesperson said: 'We would like to offer our sincere condolences and apologies to the family of Jack McKenzie for his sad death and the failings identified in this report. 'We are grateful to Sheriff Collins for his recommendations, which we will fully consider as we continue to deliver systemic change, at pace, in a way which keeps young people in our care safe, during one of the most challenging and vulnerable periods of their lives."

Scottish Prison Service 'closed ranks' after young offender took his own life
Scottish Prison Service 'closed ranks' after young offender took his own life

STV News

time20-05-2025

  • STV News

Scottish Prison Service 'closed ranks' after young offender took his own life

The Scottish Prison Service has been warned that it condoned 'bad practice' after failing to discipline prison officers after a young man took his own life at a young offenders' institution. Jack McKenzie, from Glasgow, died at Polmont YOI in September 2021 after being passed the drug etizolam. He had been on remand at Polmont for rape and sexual assault charges – which he denied – since January of that year. Mr McKenzie was pronounced dead in his cell at 7.57am on September 3, 2021, after taking his own life, which was deemed 'unpredictable' in a Fatal Accident Inquiry (FAI) determination by Sheriff Simon Collins. Mr McKenzie had been confined to his cell following an 'aggressive' outburst attributed to drugs on September 1. His death could have occurred between 3am and 7.36am, the inquiry found, however, two prison officers tasked with a 'hatch check' just after 6.30am did not do so sufficiently, and a total of seven recommendations were issued to the SPS regarding improvements. Sheriff Collins said in his determination 'poor practice must be investigated and sanctioned, not ignored and therefore – apparently – condoned'. It added: 'The purpose of imposing a sanction is not to criticise prison officers for the sake of it, but to seek to drive up standards in the hope – in the present context – of preventing the deaths of further young prisoners by suicide.' A six-month deadline was set for SPS to reduce 'abusive and bullying verbal behaviour, drug dealing, and to respond to physical disturbances' during the night, in the sheriff's determination. Mr McKenzie was described as a 'chronic drug user' who had been remanded four times in three years in Polmont YOI, however, his death was described as 'impulsive' and a report called for improvements to cell environments. His death 'might realistically have been avoided' if reasonable precautions had been taken, Sheriff Simon Collins KC said in his determination published on Tuesday morning. It comes just months after the joint inquiry into the deaths of Katie Allan, 21, and 16-year-old William Brown at Polmont. Katie and William – who was known as William Lindsay – took their lives at the institution in 2018. Sheriff Collins, who presided over the Katie Allan and William Brown FAI, which also investigated Polmont, said ten young prisoners died by suicide there between 2010 and 2023, while more than 120 prisoners died by suicide in Scottish prisons between 2011 and July 2024. The report said: 'Jack's death was spontaneous, unpredicted and unpredictable. But it is well known that prisoner suicides can be so. 'Accordingly prisoners should, insofar as reasonably possible, be detained in environments which are safe, in the sense of minimising the risk of such suicides.' The report said an audit had been done of potential suicide risks in equivalent cells and using the Manchester Tool Kit, Mr McKenzie's cell would have 'indicated the highest level of risk'. Mr McKenzie was perceived by staff as 'jovial, funny, likeable and talkative' but on drugs could be 'aggressive, agitated and anti-authority' and traded substances. However, he had never been assessed as suicidal, the report added. On September 1, Mr McKenzie smashed two phones and was restrained and confined to his cell due to becoming 'non-compliant' and intoxicated – using an order which would have expired on September 4 just after 3pm. The report said: 'There was simply nothing to indicate, prior to September 3, 2021, that Jack had any thoughts or intention of dying by suicide'. Accounts from neighbouring cellmates suggested 'that Jack was still alive at around 3am to 4am' on September 3, the report said. At 6.37am on September 3, two prison officers failed to carry out a hatch check at Mr McKenzie's cell to ensure he was safe and failed to take steps to ascertain his whereabouts, and did not log concerns on a handover, it added. A recommendation said: 'A sanction should have been imposed on both officers and/or corrective training required of them.' Governor Gerry Michie did not issue any 'disciplinary action, reprimand, warning or sanction' and neither officer was 'offered, nor required, to undertake additional training '- which was branded 'unacceptable' in the report. The report said: 'The absence of any disciplinary action, given the seriousness of the breach, and the possible seriousness of the consequences of it, is incongruous and unacceptable. 'I do not accept, as SPS submitted, that this was within the range of reasonable responses open to governor Michie. 'Rather, it was a response which sends a message to prison officers that they will not be held to account for a failure to 'do the basics well', and a message to the public that the first response of SPS to poor staff practice in the context of the death of a prisoner is to close ranks and protect its own.' Procurator Fiscal Andy Shanks, who leads on fatalities investigations for the Crown Office and Procurator Fiscal Service, said: 'The sheriff's determination, which makes significant recommendations in relation to ligature anchor point identification, reduction and prevention and the checking of cells, is extensive and detailed. 'The FAI followed a thorough and comprehensive investigation by the Procurator Fiscal who ensured that the full facts and circumstances of Jack's death were presented in evidence. ' 'My thoughts remain with Jack's loved ones at this difficult time.' A Scottish Prison Service spokesperson said: 'We would like to offer our sincere condolences and apologies to the family of Jack McKenzie for his sad death and the failings identified in this report. 'We are grateful to Sheriff Collins for his recommendations, which we will fully consider as we continue to deliver systemic change, at pace, in a way which keeps young people in our care safe, during one of the most challenging and vulnerable periods of their lives.' Get all the latest news from around the country Follow STV News Scan the QR code on your mobile device for all the latest news from around the country

Inquiry hears claims ‘cameraman flew into back of activist' in fatal crash
Inquiry hears claims ‘cameraman flew into back of activist' in fatal crash

STV News

time08-05-2025

  • General
  • STV News

Inquiry hears claims ‘cameraman flew into back of activist' in fatal crash

The trustee of a charity founded by climate activist Sacha Dench claimed that a cameraman who died following a mid-air collision 'didn't communicate by Bluetooth' and flew into the back of her, an inquiry has heard. Dan Burton, 54, died after his paramotor was involved in a crash with one flown by colleague Ms Dench, known as 'the human swan', near Loch Na Gainmhich in Sutherland, Highlands, on September 18 2021, during a bid to break a world record and raise awareness of climate change ahead of Cop26. Ms Dench suffered serious injuries and was taken to hospital in Inverness before being moved to Aberdeen, where she gave an account to a trustee of the charity she founded, Conservation Without Borders, a Fatal Accident Inquiry (FAI) at Tain Sheriff Court heard. The charity's trustee Steven Holland gave evidence and said that he signed off a risk assessment which he believed was based on previous expeditions. He said that 'two or three days' before the fatal crash there had been an issue with an electric paramotor, and defended the risk assessment which he said was likely to have been 'adapted' from the previous Flight of the Swans expedition, the inquiry heard. Mr Holland said: 'About two or three days before the incident there was a failure of an electric powermotor. The electric powermotor had caused issues from the start, they have a shorter range and have issues with pushing boundaries of technology. It was deemed to be too unreliable.' He said Mr Burton and Ms Dench had worked together previously and the cameraman 'called the shots', and that the charity's priority after his death was assisting the two women acting as ground crew as they were 'quite young', the inquiry heard. Peter Littlefair, representing Mr Burton's widow Caroline, said that a payment of £800 had been agreed for Mr Burton for the remainder of the expedition, which Mr Holland described as a 'gift' during his evidence to the inquiry. Giving evidence, Mr Holland said Mr Burton 'didn't communicate by Bluetooth, she did not hear his voice at all, I think Bluetooth was live all the time so if someone was in range it would connect'. He added: 'If he was within range and had spoken she would have been able to hear.' Mr Holland said: 'I know it was good enough for normal functional conversations.' He also told the inquiry that Mr Burton made all the decisions around flying, but described Ms Dench as 'operational lead'. Mr Littlefair said: 'Do you think an external reviewer would have been more appropriate?' Mr Holland said: 'How he came to fly into the back of her and didn't communicate, I'm not sure what a risk assessment could do about that. Sacha was saying she was hit from behind.' Under questioning from fiscal depute Jemma Eadie, Mr Holland defended the risk assessment. Ms Eadie said: 'Asked if you made independent inquiries, you said you had made an assumption. You read this as a non-pilot, effectively signing the risk assessment off. 'You're saying 'on the face of this, this looks reasonable' without having pilot experience.' Mr Holland said: 'They both had experience flying in the UK and across Europe, I think it's a safe assumption on what they had done before and since Flight of the Swans.' Earlier the inquiry heard that Mr Burton had raised concerns about stress before the collision. Charlotte Harrison-Littlefield, formerly social media manager for Conservation Without Borders, told the inquiry: 'There were several occasions where Dan Burton expressed to me and others about frustrations with the working environment and general progress of (the) expedition. 'The expedition was chronically behind in terms of where we should be geographically and how many people we interviewed. The time the expedition was due to take – six weeks – was extended to be a lot more. 'It was quite a stressful working environment, we were asked to get a lot done and didn't have time.' During cross-examination by Peter Anderson, representing the insurers of the British Hang Gliding and Paragliding Association, the inquiry heard that Mr Burton had been 'shaken' by a landing after a flight earlier the same day. Ms Harrison-Littlefield said: 'I remember that the landing from the morning flight was not ideal. I remember that Dan was quite shaken when I collected him, I picked him up in the car.' She told the inquiry that Ms Dench 'had the final say' over decisions around flying. Giving evidence during cross-examination by Ms Dench's representative, Simon Richards, she described Ms Dench as a 'celebrity' and said that Mr Burton would fly above her, in order to capture her in footage, the inquiry heard. The inquiry continues in front of Sheriff Neil Wilson. Get all the latest news from around the country Follow STV News Scan the QR code on your mobile device for all the latest news from around the country

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