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 Deborah McElvanney, aged 27 years who resided at 11 Waddell Court, Glasgow, died at Glasgow Royal Infirmary at 20.56 hours on 27 April 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 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 Deborah McElvanney had been an intravenous drug user for about two years prior to her death. She was not an habitual injector. When injecting she had difficulty in finding a vein and required assistance to do so. She might on occasions miss a vein but was not known to deliberately inject into muscle.

(2) Dr J McLean, a general medical practitioner attended the deceased on 3 and 31 March 2000. Dr McLean noted marks and swellings on her hand and arm consistent with her continuing to inject heroin. The deceased at that time was in receipt of a methadone prescription.

(3) The deceased attended at the Accident and Emergency Department of Glasgow Royal Infirmary at 12.22 hours on 20 April 2000 complaining of injury to the right arm. The triage note records: "Injected into right hand two days ago. Now swollen and infected". She was seen by a member of the medical staff who noted that her arm was massively swollen. He was concerned by the possibility of compartment syndrome, which causes ischaemia and consequent nerve damage. He referred her to orthopaedic assessment and in turn she was seen by vascular surgeons. They noted that she had normal circulation, pulses and sensation. There was no arterial insufficiency and compartment syndrome was excluded. She was admitted, the plan being to x-ray the limb, elevate it, apply subcutaneous anti coagulants and provide analgesics.

(4) At about 14.30 hours on 21 April the deceased was given methadone orally following confirmation with her GP that she was on a methadone programme.

(5) On 22 April she was continuing to complain of pain in her arm. An area of blistering on the dorsum of the hand was noted with surrounding erythema. She was apyrexial overnight and was prescribed flucloxacillin on 23 April. Following consultation with a bacteriologist benzylpenicillin was added. Her white blood cell count was high at 29.3.

(6) On 24 April she was seen by a consultant plastic surgeon. He noted her to be apyrexial, systemically well, alert and orientated. He observed a necrotic blistered wound, more consistent with injection injury than with a history of hyperextension which the patient described to him. He had necrotising fasciitis in contemplation and decided to excise the wound in theatre to remove any dead skin and tissue and check the underlying blood supply to skin and muscle. That procedure was duly carried out at 17.00 on said date. Skin was extensively exposed and all dead skin was removed. There did not appear to be signs of necrotising fasciitis.

(7) The condition of the deceased was reviewed on 25 April and again on 26 April. She remained conscious, alert and in no physical distress. Results of blood tests and microbiology became available in the course of the morning. These revealed the presence of anaerobic infection, probably clostridium of an unidentified type. The white cell count had risen to 48. There was also a result indicative of infection damage to muscle, the first clear indication of necrotising fasciitis. As a result further extensive surgery was carried out on 26 April involving extensive debridement of the right arm, shoulder and lateral aspect of the torso. Following surgery she required to be admitted to the Intensive Treatment Unit for respiratory support.

(8) Thereafter the condition of the deceased deteriorated rapidly. She developed adult respiratory distress syndrome, a lung condition which is a recognised complication of sepsis and surgical trauma. She died at 20.56 hours on 27 April. No post-mortem examination was carried out.

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] The death of Miss McElvanney occurred in Glasgow Royal Infirmary on the day after the death of Andrea McQuilter, the first falling within the ambit of this Inquiry. Miss McElvanney's death differed, however, in that she had been an in-patient in hospital for about seven days prior to her death. The cause of it - necrotising fasciitis with consequent release of toxins causing multi-organ failure, was not in doubt and the death was not initially the subject of a report to the Procurator Fiscal. For that reason no post-mortem examination was carried out. I am satisfied that no criticism attaches to the medical authorities for this.

[3] Although the presence of Clostridium Novyi bacteria has not been established in this case the generalised finding of the presence of a Clostridium type of infection and the manner and circumstances of death point very strongly to this case falling within the outbreak which occurred at the time. The manner of Miss McElvanney's deterioration illustrates graphically the difficulties faced by medical practitioners in dealing with this type of infection and the onset of necrotising fasciitis. There was no sign of it when the surgical procedure was carried out on 24 April to clear away dead tissue in order to control infection and assist healing. By 26 April when the presence of a Clostridium infection was discovered Miss McElvanney had been in receipt of massive antibiotic treatment for at least 48 hours. When the further surgical intervention took place on 26 April this involved removal of a significant amount of tissue from the whole area of the right arm and part of the lateral aspect of the right torso. Despite this, it is clear that toxins had been released into the system with fatal consequences. I am satisfied that nothing could have been done to save Miss McElvanney's life.

[5] There was a certain amount of criticism by the father and partner of the deceased as to the general level of concern on the part of the medical profession for drug addicts and a particular fear on the part of the deceased of going into hospital. So far as the latter is concerned it is clear from the relevant records that she had consulted her general practitioner on 10 occasions in the two months prior to her death so did not appear to have a difficulty about seeking medical attention at that level. It was also suggested that she had not been given methadone whilst in the Royal Infirmary. This is clearly contradicted by the medical records and indeed there is evidence of a telephone call made to the GP on 20 April to seek a confirmation that the deceased was on a methadone prescription. The situation regarding the cause of her condition is also somewhat complicated by the fact that she maintained a position whilst in hospital that the pain in her arm had been caused by a fight. The surgical findings effectively rule this out and confirm that damage to tissue was caused by an injection. One is left with the suspicion that the deceased was not anxious to admit to the hospital authorities that she was still a heroin injector as this would have prejudiced the availability of methadone, and that her concern about going into hospital related to that and to the non-availability of drugs.

[7] So far as medical treatment is concerned the deceased's father conceded in cross-examination that he had no criticism of the doctors who had attended his daughter. An independent surgeon Mr Murie has reported in detail on the circumstances of this case and that report confirms the view, which the evidence itself indicates, that everything that could possibly be done for Miss McElvanney was carried out.