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 MICHAEL TAGGART, aged 36 years who resided at Flat 115, 27 Castlebay Drive, Milton, Glasgow died at Stobhill Hospital, Glasgow at 08.35 hours on 16 May 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 cause of death:

(1) The deceased had been a drug user for about 20 years. He had progressed to heroin at an early age and despite intermittent efforts to break the habit remained heavily addicted. He had difficulty finding veins into which to inject and on at least a few occasions injected into muscle.

(2) From about December 1999 the deceased and his girlfriend Roslyn Duff with whom he resided made an attempt to cut down on the use of heroin. They were prescribed methadone but in addition injected heroin of significantly levels particularly when Miss Duff received her monthly disability allowance. In particular they were injecting on or about 28 and 29 April 2000.

(3) The deceased attended at the Casualty Department of Stobhill Hospital at 14.00 on 2 May 2000. He was noted to have "muscle popped" three days before, since when he had developed a large abscess on the left buttock. The nature of the abscess was such that a decision was taken to admit him immediately for incision and drainage. He was noted to be showing signs of generalised sepsis and had a high white cell count at 20.6.

(4) The deceased was taken to theatre later on on 2 May. The abscess was incised under general anaesthetic and a large amount of pus released. A large abscess cavity was noted and all necrotic material around it was debrided. The operating surgeon noted that it was difficult to envisage this healing well and that the input of plastic surgeons might be required. It was recommended that he remain on antibiotics and cefuroxime and metronidazole were administered, albeit with difficulty due to lack of venous access.

(5) The deceased remained in hospital until 5 May. On 3 May he was noted as apyrexial and stable. On 4 May he was mobile and tolerating fluids and diet. He continued to receive antibiotics and morphine and when discharged was given two days supply of cephalexin and metronidazole, along with dihydrococidine and diclofenac for pain relief.

(6) On 6 and 7 May a district nurse attended at the deceased's home to clean, repack and dress the wound. The entry in the relevant nursing notes for 6 May includes reference to metronidazole as part of the deceased's medication.

(7) On 7 May Miss Duff arranged for the deceased to visit her GP Dr Trollen at this surgery. Dr Trollen noted that the deceased was an intravenous user; that he was on dihydrocodeine and was buying valium. He also recorded that the deceased was "on antibiotics from Stobhill". Dr Trollen gave further prescription of dihydrocodeine and diclofenac along with a gel to be used for packing the wound and a laxative. He described the site of the wound as "huge".

[8] From about 10 May Miss Duff noticed a changed in the deceased's condition. He appeared to lose his appetite, was grey, bloated and feeling nauseous. He began to complain of pain in the right buttock. A district nurse attended on 13 May and nothing of significance was noted. A further visit was made on 14 May. On that occasion the nurse observed the right buttock to be painful, red and hard to touch. The nurse telephoned the GP deputising service but after she left Miss Duff called for an ambulance and the deceased was conveyed to Stobhill Hospital.

(9) The deceased was admitted to the Casualty Department at 11.10 hours. His pulse was elevated and his temperature (35.6ºc) low. He was seen by a surgical senior house officer who noted that the right buttock was hot, discoloured, tendered and hard. The left buttock was "healing very well". The impression was of cellulitis and sepsis. Examination of the right buttock by ultrasound was carried out, revealing bubbles indicative of pockets of gas. The white cell count was 41.9.

(10) In the course of the evening of 14 May the deceased underwent surgery. Necrotic skin and muscle was debrided and oedema fluid released. He was taken to the High Dependency Unit. During 15 May examination of swabs and tissue samples indicated infection from both aerobic and anaerobic organisms. At midday the right buttock abscess appeared to be more inflamed and necrotic. His temperature was very low. He was returned to theatre for further extensive debridement. He was moved to the Intensive Treatment Unit where signs of multiple failure were noted.

(11) In the early hours of 16 May the deceased was noted to be clinically dehydrated with marked peripheral oedema. The white cell count had risen to 80.6. There was loss of cardiac function. Despite attempts to maintain life he died at 08.35 hours.

(12) Post-mortem examination revealed substantial bilateral pleural effusions and fluid in the peritoneal cavity. All the findings were consistent with multiple organ failure. Anti-mortem microbiological produced a growth of clostridium perfringens from a sample of tissue from the right thigh.

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] There is no doubt that this death arose from multiple organ failure consequent upon the release of toxin producing organisms. A finding of clostridial myonecrosis is appropriate in addition to necrotising fasciitis in view of specific findings of damage to muscle. Although there is no specific finding of clostridium novyi infection the finding of related clostridia and the characteristics of this death lead to the conclusion that clostridum novyi infection was likely to have been involved.

[3] There is no doubt that the deceased was given proper treatment for the presenting condition when he attended at Stobhill Hospital on 2 May. It is equally clear that he was not reluctant to undergo medical treatment and it is in consequence a necessary conclusion that nothing could have been done in this case to save his life. Standing that it is perhaps unnecessary to express any view on two matters of controversy which were raised in the course of the evidence. These were (a) whether he was prescribed antibiotics at the time of his discharge from Stobhill and (b) whether he took drugs subsequent to that discharge. I shall give my views on these matters for such relevance as they may have.

[4] Although Miss Duff was emphatic that the deceased was not given antibiotics the weight of evidence overwhelmingly suggests that they were provided. They were prescribed and shown on the "discharge and medicine prescription form" contained in the deceased's medical records and the prescription of antibiotics was entirely in accordance with surgical recommendations. Dr Trollen the GP who saw the deceased after his discharge from Stobhill specifically recorded that he was receiving antibiotics prescribed by that hospital. There is also a note in the health visitor's records to the effect that the deceased was on antibiotics. Moreover, it is doubtful if the infection of the left buttock would have cleared to the extent which it did if antibiotics had not been prescribed.

[5] The subsequent infection of the right buttock in itself tends to suggest that the deceased injected into it subsequent to his discharge from Stobhill. Dr Hood, the Clinical Microbiologist, was of the view that there appeared to be an "incubation" period of about five days from the point where an individual became infected until symptoms became critical. An injection about a week after discharge from Stobhill would appear to fit that picture. Whilst Miss Duff said that she did not recall the deceased having "muscle popped" at about that time it was possible that he had done so. The evidence overall strongly suggests that he did.

[6] Finally, although the matter was not discussed in any detail it is to be observed that the deceased handed to Dr Trollen a note which indicated the he "knew for a fact" that the deaths of heroin addicts were due to citric acid. In the light of the evidence led at the Inquiry there is little doubt that this opinion was wrong.