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 SAMUEL JOHNSTONE, aged 34 years who resided at Hope House, 14 Clyde Street, Glasgow died at The Royal Alexandra Hospital, Paisley at 13.30 hours on 5 June 2000;

(b) that the cause of death was multi-organ failure secondary to clostridial myonecrosis, 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 circumstances of death:

(1) The deceased had been a heroin addict for many years. He was homeless and a vendor of "The Big Issue" magazine. He became a resident at the Salvation Army Hostel at Hope House, 14 Clyde Street, on 26 April 2000. He was known to suffer from poor health.

(2) The deceased was unwell prior to 1 June 2000 and on that date was advised to attend Glasgow Royal Infirmary because of what appeared to be abscesses on his legs. He refused to go and expressed the view that staff at the Infirmary were unsympathetic to drug addicts. An ambulance was called to the hostel and he was seen by an experienced ambulance technician at 15.32 hours. He was lying in bed, appeared emaciated, had vomited and was described as being "not in very good shape at all". He refused to go to hospital.

(3) The deceased's general practitioner was advised by ambulance control that the deceased had refused to attend hospital following a 999 call. The GP telephoned Hope House and spoke to a member of staff. He offered to see the deceased at any time and confirmed that staff and the deceased were aware of the current outbreak of infection affecting intravenous injectors.

(4) On 2 June the deceased was persuaded to attend the Victoria Infirmary accompanied by an outreach worker and a member of the "Big Issue" staff. He was taken there in a van and on arrival was conveyed to the casualty department in a wheel chair. His arrival was timed at 11.03. His presenting complaint was noted as "sudden illness" his temperature at 35.9 degrees centigrade was normal.

(5) The deceased was seen by a consultant accident and emergency surgeon who observed that he was fully orientated and gave a coherent history, which involved "skin popping" in both legs. He was examined, and the results of that examination noted as follows: "Induration over lateral aspect of left thigh. No cellulitis. Apyrexial. Multiple lacerations and scaring over both legs anterior aspects". The surgeon was aware of the outbreak of infection amongst drug users and was specifically concerned as to the presence of abscesses, spreading infection, or deep vein thrombosis but saw no sign of any. He described the legs as being "of dramatic appearance", indicative of a long standing injecting habit. He was of the view that in the absence of signs of cellulitis it was inappropriate to prescribe antibiotics, and the deceased did not require to be admitted. He warned the deceased of the danger of continuing to inject. The deceased was discharged at 11.25 hours. Later that day a member of the staff of Hope House obtained from the GP a prescription of Cocodamol for the deceased.

(6) On 3 June and on the morning of 4 June the deceased was continuing to vomit and complained of stomach pains. He was taken to the Accident and Emergency Department of Glasgow Royal Infirmary on 4 June. His arrival being timed at 15.40. The presenting complaint was of vomiting blood. A history of intravenous drug use, ulcers and left leg pain was noted. His blood pressure and pulse were both normal, his temperature slightly low. He was seen by a casualty officer who noted, with a "question mark" the presence of an abscess on the left thigh, and widespread cellulitis. He referred the deceased for general surgery.

(7) The deceased was seen by a surgical senior house officer at 19.45. She was of the view that there was no cellulitis. What was present was thickening of the skin. She described it as "cold - like touching wood". There was no hot red swollen abscess or firey skin. With the heightened awareness of infection affecting drug users she arranged for broad spectrum antibiotics by intravenous central line and for blood cultures. She also sought a view from the surgical specialist registrar who largely confirmed her findings, noting that cellulitis was "minimal". He noted that the deceased "potentially has muscle necrosis" and might need treatment in theatre.

(8) At 20.10 hours the central line was inserted and antibiotics administered. The deceased received morphine. He appeared very sensitive to this and his conscious level decreased, suggesting that he had recently taken drugs. At 21.30 radiology results showed "oedematous/inflamed subcutaneous plans in lateral posterium compartment mainly mid-thighs". At the same time haematology results indicated signs of renal failure and there was a very high white cell count of 63.6. He was taken to theatre where the presence of necrotising fasciitis was confirmed and in consequence debridement involving substantial areas of muscle and skin tissue of the left thigh was carried out.

(9) Overnight the deceased was transferred to the Royal Alexandria Hospital, Paisley as a result of a shortage of Intensive Treatment beds at Glasgow Royal Infirmary. He was under the care of the shock team during transfer. It was apparent that his condition was critical with signs of renal failure. Despite every effort to support life he became very unstable and died in said hospital at 13.30 hours.

(10) Post-mortem examination revealed signs of chronic skin and muscle popping with multiple scars, bruises and ulcers although none of these had pus formation associated with them. There were extensive pleural and small pericardial effusions and markedly oedematous lungs. Microbiological examination of blood samples confirmed the presence of Staphylococcus Aureus.

NOTE:

[1] For my comments on the background to the multiplicity of deaths 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 this case necrotising fasciitis was confirmed in theatre on the evening prior to the deceased's death. That, taken with the pattern of rapid deterioration to death and the post-mortem findings of pleural effusions and oedematous lungs points strongly to the presence of a clostridial infection, although only Staphylococcus Aureus was specifically identified.

[3] This case understandably gave rise to concern due to the attendance of the deceased at the Victoria Infirmary on 2 June and his discharge after a relatively short consultation. That consultation was carried out by Mr Ian Anderson, an experienced consultant in Accident and Emergency medicine. Mr Anderson was fully aware of the outbreak of infection affecting drug users and was particularly concerned to identify the presence of abscesses, spreading infection, or deep vein thrombosis. No signs of these were present and all information subsequently obtained confirms this view. The post-mortem examination pointed to the absence of "frank pus formation" which would have been indicative of the presence of abscesses. Miss Doran, a senior house officer, confirmed the absence of cellulitis when she saw the deceased on 4 June, a view which was confirmed by a surgical specialist registrar. It appears likely that the indurated condition of the deceased's lower limbs, which by all accounts appears to have been most dramatic, was mistakenly described by less experienced staff as cellulitis.

[4] In that situation I am satisfied that no criticism attaches to the fact that the deceased was not kept in hospital at the time of his attendance on 4 June. There was some conflict in the evidence as to what passed between nursing staff and those who took the deceased to hospital at that time. I do not consider that there is anything to be gained by attempting to resolve that conflict. Overall I am satisfied that sadly this is another case in which the outward signs of the devastating infection were not such as to point to its existence. By the time extensive debridement of tissue took place on the evening of 4 June the release of toxins was such that Mr Johnstone's death was inevitable.

[5] In relation to this death there was considerable evidence led as to the perceptions of drug users in relation to the level of treatment and sympathy which they were likely to receive from particular hospitals. I have dealt with that matter in the General Note and do not intend to develop it further in relation to the circumstances of Mr Johnstone's death. It does appear so far as he was concerned that he was not the easiest of patients. His general practitioner revealed that he had been removed from a previous doctor's list due to threatening behaviour. There is no doubt that he was heavily addicted to heroin at the time of his death and there is a distinct likelihood that his reluctance to attend hospital stemmed from a belief that he would be cut off from his supplies without adequate remedial treatment for withdrawal symptoms. The fact remains that he was persuaded to attend for medical treatment three days before his death and that this failed to reveal the presence of the infection to which he later succumbed.

[6] Lastly, it is appropriate to acknowledge the considerable levels of dedication, concern and support which Mr Johnstone was given during the events leading up to his death by the staff of Hope House and members of the Big Issue organisation.