SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH

Inquiry held under the Fatal Accidents

And Sudden Deaths Inquiry (Scotland)

Act 1976

DETERMINATION

By

Sheriff Kathrine EC Mackie

Following an Inquiry held at Edinburgh on 7^th and 8^th December 2009 into the death of JOHN ROSS

Edinburgh December 2009

The Sheriff having considered the evidence adduced and submissions thereon, DETERMINES in terms of the Fatal Accidents and Sudden Deaths (Scotland) Act 1976

[1]               That, in terms of section 6(1)(a), John Ross, born on 16^th December 1961, latterly of HMP Edinburgh, died at the Edinburgh Royal Infirmary at 20.05 hours on 12^th October 2008.

[2]               That in terms of section 6(1)(b) the cause of death was:-

1                    (a) Pulmonary embolism

(b) Bronchopneumonia with septicaemia

(c) Acute renal failure

(d) cystic kidney disease

2 Chronic hepatitis B and C

NOTE

[1]               At the time of his death John Ross was a person in legal custody having been sentenced on 29^th September 2008 to a period of three months imprisonment. Accordingly the provisions of section 1(1)(a)(ii) of the Fatal Accidents and Sudden Deaths (Inquiry)(Scotland) Act 1976 apply.

[2]               In 2002 Mr Ross was diagnosed with renal failure and required dialysis three times per week. He had a history of intravenous drug misuse. His compliance with treatment was poor. He suffered from chronic under dialysis leading to a reduced ability to resist infection. As a result of his history of drug misuse there were difficulties in achieving good access for dialysis. A plastic catheter was inserted in the right common femoral vein in the groin area. This leads to a heightened risk of infection.

[3]               Arrangements were made by HMP Edinburgh for Mr Ross to be escorted to the Royal Infirmary Edinburgh for dialysis. Mr Ross attended the Royal Infirmary on various dates including 5^th October 2008. After dialysis he was admitted as an in-patient for removal on 6^th October 2008 of an infected catheter and insertion of a new line.

[4]               There were difficulties in attempting to establish a new access for dialysis. Mr Ross's condition deteriorated following the procedure. He was unable to tolerate full dialysis. He was prescribed antibiotic treatment for infection, fluids were administered and he was fed by naso-gastric tube. He was also prescribed painkillers.

[5]               He remained an in-patient. Initially his condition appeared to improve. On 11^th October 2008 he was displaying signs of infection in his chest despite being prescribed a wide spectrum antibiotic. Further antibiotics were prescribed. On 12^th October 2008 he was observed to be very unwell. While he tolerated dialysis it was not considered to be effective. At about 6pm there was a further serious deterioration in his condition. Consideration was given to placing Mr Ross on a ventilator and to surgical procedures in an attempt to help him recover. He was not thought fit to survive the procedures. A review of his medical history suggested that he was suffering multi-organ failure and was unlikely to survive. Palliative care was administered. When such care was withdrawn Mr Ross died quickly.

[6]               Throughout his admission Mr Ross was escorted by two Prison Custody Officers. Until shortly before his death he remained attached to one of the officers by a 3 metre chain. That was removed on the officer's initiative when it became apparent that Mr Ross required urgent care. Appropriate authorisation for its removal was obtained retrospectively.

[7]               Having heard evidence from Alan Beatson and Chris Dedecker both nurses at HMP Edinburgh, Dr Smith of HMP Health Centre, Dr Millar, Mr Ross's GP, Mr Sweeney PCO, Miss Boulton Staff Nurse, Professor Kerbach Wighton and in particular Drs Richards and Dimova who treated Mr Ross and having considered the joint minute and all productions I am satisfied that I should make only formal findings. I make no findings in terms of section 6(1)(c) to (d).

[8]               I would observe that Mr Ross suffered from a serious life threatening illness. His lifestyle and personality were not well suited to the regime to which he was subject and it is clear that he struggled to adjust to the restrictive requirements of dialysis. Notwithstanding his at times challenging and frustrating behaviour it is clear from the evidence and the records that Mr Ross received from the NHS and albeit briefly from SPS an excellent standard of care and treatment.