Scottish Sheriff Court Decisions

GLASGOW, 25 February 2002.

The Sheriff Principal, having considered all the evidence adduced, DETERMINES: in terms of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976 Section 6(1) (a) that SHARON JACONELLI, aged 29 years who resided at Inglefield Street Hostel, 19-21 Inglefield Street, Glasgow died at Victoria Infirmary, Glasgow at 07.17 hours on 5 May 2000;

(b) that the cause of death was multi-organ failure secondary to necrotising fasciitis and toxin producing organisms;

(c) that there is no evidence of any precautions which might have avoided the death of the deceased;

(d) that the death of the deceased was not caused by any defect in a system of work;

(e) that the following facts are relevant to the cause of death:

(1) The deceased had been a drug user for about 10 years and was in the habit of injecting heroin.

(2) The deceased attended at the Victoria Infirmary on 19.41 hours on 2 May 2000 having been conveyed thereby emergency ambulance. The present complaint was "groin abscess". She was seen by medical staff at 20.20 hours. It was noted noted that left leg was grossly swollen, tender and red in the groin region. She was referred for assessment by surgeons who noted that she had a complaint of increased swelling since injecting into the groin area three days previously. They noted that she was apyrexial; there was erythema and mild oedema in the groin area which was very tender. The provisional diagnosis was cellulitis or deep vein thrombosis. She was admitted to the surgical ward, the immediate plan being to treat her with broad spectrum antibiotics.

(3) Following admission to the surgical ward it was found necessary to insert a jugular line due to the absence of a vein. Antibiotics namely benzylpenicillin, flucloxacillin and metronidazole were administered. In the course of the evening the deceased was noted to be drowsy with "small pupils". The left thigh remained erythematous and tender. Blood tests at 23.25 revealed a high white cell count at 43.0 and signs of dehydration. In the early hours of the morning of 3 May she became restless and at about 06.30 hours fell out of her bed. She was not injured. In the course of the morning she became, according to the nursing notes, "increasingly disgruntled" and eventually insisted on being discharged after being warned of the danger of smoking in bed. She was seen by her father at his home shortly thereafter. At that stage she appeared to have resolved to return to hospital and attended at said Accident and Emergency Department at 14.47 hours.

(4) The deceased was re-admitted to the surgical ward at 17.40 on 3 May. She admitted to having attempted to inject heroin whilst out of hospital. Her left thigh was swollen and tense. She was seen by a consultant who considered her to be much more unwell than the degree of inflammation of the thigh itself suggested. The overall impression, taking into account the high white cell count and other test results, was of sepsis. It was noted that she "needs thigh explored tonight". Prior to surgery a "Doppler" scan was carried out. This revealed extensive subcutaneous oedema but no focal collection of fluid. When opened the tissue of the thigh appeared fairly healthy; there was no liquefied or black tissue and such clinical changes as there were did not appear typical of necrotising fasciitis.

(5) In the course of 4 May the deceased was regularly given diamorphine for pain relief. Following discussion with Dr Redding, Consultation Microbiologist, Clindamycin was added to the range of antibiotics. The symptoms of sepsis appeared to worsen in the course of the day and in view of that and in the knowledge that two patients (Conlan and McGlinchey) with similar symptoms had died in the immediately proceeding days a decision was taken to explore the thigh again in theatre.

(6) This was carried out in the evening of 4 May. Following initial decompression procedure it was noted that underlying tissue was necrotic and oedematous and veins thrombosed. It was considered necessary to carry out extensive debridement which involved circumferential removal of tissue from just above the knee to the groin and over the lower left half of the abdominal wall.

(7) The deceased was moved to the intensive care unit. In the course of the night she became increasingly unresponsive. At 00.17 she became asystolic and was pronounced dead.

(8) Post-mortem examination revealed large bilateral pleural effusions. The overall clinical picture and post-mortem findings were in keeping with death resulting from multiple organ failure caused by a toxin producing organism.

NOTE:

[1] For my comments on the background to the multiplicity of death of injecting drug users in Glasgow during the period April to August 2000 reference is made to the General Note appended to the Determination in the case of Andrea McQuilter.

[2] In the case of Miss Jaconelli whilst there is no positive finding of clostridum novyi infection the clinical picture involving rapid deterioration and death arising from multiple organ failure is entirely consistent with that being the cause. Given that this was one of the earliest cases the procedures carried out were appropriate. In particular the decision taken by the consultant Miss Reid to carry out exploratory surgery on the evening of 3 May was appropriate. The findings at that stage indicate how, even with such surgery the presence of necrotising fasciitis may not be detected until too late.

[3] The only other one minor matter arises in connection with this death. There is a note in the medical records, made by a junior house officer that "Hospital policy is not to prescribe methadone as it is the GP's responsibility". It is not clear whether this arose as a result of a request from the deceased for methadone. The observation that the prescription of methadone "is not hospital policy" is incorrect. However, such prescription in this case would have been wholly inappropriate given that the deceased was receiving an opiate painkiller and was probably an active heroin injector at the time. This matter is wholly unrelated to the cause of death.