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 PAUL McMAHON, aged 31 years, who resided at Flat 14/2, 2 Fountainwell Place, Glasgow, died at Glasgow Royal Infirmary at 19.05 hours on 1 May 2000;

(b) that the cause of death was multiple 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 circumstances of death:

(1) The deceased had been addicted to drugs since the age of about 17. He lived with Elaine Mullen who was also addicted to drugs and who died in similar circumstances on 10  May 2000.

(2) The deceased attended at the Accident and Emergency Department of Glasgow Royal Infirmary at 20.51 hours on 19 April 2000. He was complaining of swelling of the left buttock. He was examined by a member of the medical staff at 21.40 hours who noted "muscle pops because has difficulty getting a vein". The left buttock was described as hard, "tense and erythematous". His white cell count was high at 27. Suspecting cellulitis or compartment syndrome the Accident and Emergency doctor referred him to the surgeons and he was admitted to ward 26.

(3) He was examined in the surgical ward in the course of the evening. He admitted to injecting into his left buttock two days ago. The presenting signs were confirmed. The impression was "likely abscess left buttock muscles". The abscess was aspirated with a needle but no fluid was removed and no organisms were seen. He was prescribed antibiotics, augmentin and metronidazole.

(4) The deceased became restless overnight. He was seen at an early ward round when he was recorded as feeling better. It was intended to carry out an ultrasound to confirm the absence of fluid but the deceased refused to remain in hospital and discharged himself against advice at about 09.30.

(5) The deceased was returned to said Accident and Emergency Department by emergency ambulance at 14.04 hours on 1 May 2000. He was found to be generally unwell and complained of being short of breath. He disclosed that he had been vomiting and drowsy since leaving hospital on 20 April. He had a low temperature at 34.7 and a high white cell count at 48.9. He had a hard indurated left buttock. He was seen by a specialist registrar with a view to admission to the Intensive Care Unit. The conclusion was that he was "very dehydrated with respiratory compensation of a mild metabolic acidosis. Cardiovascular and respiratory status stable. Glascow, scale 15". The decision was that he needed to be rehydrated and further investigated by surgeons.

(6) He was seen by a surgeon at 16.30 hours. His temperature was lower still. He had symptoms of shock and signs of renal failure. The impression was of septicaemia secondary to an intra abdominal abscess. An ultrasound was required. This was carried out with difficulty at 18.00 pm. It revealed a large infusion of pus in the abdomen and peritoneum. Within 30 minutes the deceased went into cardiac arrest and died five minutes later.

(7) Post-mortem examination revealed large quantities of straw coloured fluid in the pleural cavities and pericardial sac. There was extensive oedema fluid in the subcutaneous fascia of both legs. Microscopic examination of tissue from both buttocks and right thigh showed features of necrotising fasciitis. The overall clinical and post-mortem picture was of multiple organ failure caused by toxin producing organisms, the extensive oedema being consistent with a Clostridium Novyi type of infection.

[1] From 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] There is no doubt that on his second presentation at hospital Mr McMahon was gravely ill and the infection which killed him was at an advanced stage. Nothing could have been done to save him at that time. The pathologist who carried out the post-mortem said that she had never seen such extensive oedema in tissue. The pericardial effusion of the size discovered would undoubtedly have been fatal.

[3] The traces of necrotising fasciitis were only observable on microscopic examination post-mortem.

[4] The only issue which might arise is whether all appropriate steps were taken when Mr McMahon presented at hospital on 19 April. There is the possibility that if he had not self-discharged on the following day further medical treatment might have saved him. On the other hand, in the light of the evidence of Dr Hood it is most probable that the fatal infection occurred as a result of "muscle popping" subsequent to 20 April, and that the infection caused by that spread very rapidly indeed.