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 JAMES McNICOL, aged 28 years who resided at 48 Shapinsay Street, Milton, Glasgow, died at Stobhill Hospital, Glasgow at 22.45 hours on 17 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 heroin addict for at least three years prior to his death. Latterly he was injecting into skin or muscle due to a difficulty in finding veins. He was injecting almost hourly.

(2) The deceased lived at 48 Shapinsay Street, Milton, with a partner Susan Shivers also a heroin addict. Miss Shivers and the deceased purchased heroin from common sources. On 5 May 2000 Miss Shivers was admitted to Stobhill Hospital for treatment of an abscess. She remained in hospital following drainage of the abscess and received intravenous antibiotic treatment. The deceased visited her daily. For about a week prior to 12 May he had been complaining of ill health. He was sweating, had back pain and was short of breath. He was unwilling to undergo medical treatment.

(3) The deceased collapsed whilst visiting Miss Shivers on 12 May. He was taken to the Casualty Department at Stobhill at 14.15 hours. He was complaining of tightness over the front of the abdomen and of feeling agitated and anxious. His blood pressure, pulse and temperature were all normal as were blood test results. He looked unwell and was admitted, largely as a precautionary measure because of the heightened awareness of illness amongst intravenous drug users at the time.

(4) When examined in the surgical receiving ward it was noted that his left leg was bigger than the right but there was no calf tenderness. Although suspected, no obvious evidence of deep vein thrombosis or pulmonary embolism was noted. Arrangements were made for specialised blood tests on the following day. His condition was unchanged early on 13 May. He was prescribed methadone, dihydrocodeine and diazepam as well as broad spectrum antibiotics.

(5) On the afternoon of 13 May the deceased suffered a cardiac arrest. Over the next four days he remained critically ill. He was examined by CAT scan and ultrasound without significant results. He continued to receive antibiotics. On 14 May there were signs of breakdown of muscle tissue. The cause of his condition could not be diagnosed. He slowly deteriorated and despite increasing doses of adrenaline ceased to respond and was pronounced dead at 22.45 hours on 17 May.

(6) Post-mortem examination revealed substantial quantities of straw coloured fluid in pleural cavities. Both legs were swollen with tissue oedema and there was an abscess cavity in the left thigh. Microscopic examination of tissue from that thigh showed necrotising fasciitis with a small central area of necrosis deep in subcutaneous tissue.

[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 the general clinical picture and the post-mortem findings lead to the clear conclusion that a localised infection in the left thigh of the deceased led to necrotising fasciitis with a consequent release of deadly toxins causing multiple organ failure. Although there is no specific bacteriological finding, the presence of anaerobic bacteria such as clostridum novyi appears to be the most likely source of infection particularly in the light of the failure to respond to a wide range of antibiotics.

[3] An unusual feature of this case is that despite extensive investigation, including ultrasound examination in particular, the cause of the deceased's condition could not be traced. I am satisfied that the insidious nature of the condition affecting him, and the relatively small and deeply sited nature of the source of infection, made specific diagnosis effectively impossible and that as a result there was no treatment which could have averted his death.

[4] Miss Shivers made certain complaints about failure to provide the deceased with adequate pain relief. It is clear from the medical records that he received a variety of painkillers and methadone at least from 13 May onwards. It may be that the medication thought appropriate by her was not prescribed immediately, but that would not have been appropriate until proper investigation was carried out. There is no substance for criticism of the treatment given in this respect.