Scottish Sheriff Court Decisions

SHERIFFDOM OF GLASGOW AND STRATHKELVIN AT GLASGOW

 

B178/10 2010 FAI 31

 

 

 

 

 

 

INQUIRY HELD UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976, SECTION 1(1)(b)

DETERMINATION   by IAN HARPER LAWSON MILLER, Esquire Advocate, Sheriff of the Sheriffdom of Glasgow and Strathkelvin   following an Inquiry held at Glasgow on 14th to 17th June 2010   into the death of MILDRED ROSENSHINE

 

 

 

GLASGOW, JULY 2010.

 

The sheriff, having resumed consideration of the evidence, productions and the submissions thereon,

 

FINDS AND DETERMINES:

Under and in terms of section 6(1) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, that:

(a) Mildred Rosenshine, who was born on 8^th February 1925, and who resided latterly at 70 Crookfur Cottages, Crookfur Road, Newton Mearns, G77 6JY died within the Victoria Infirmary, Glasgow G42 9TY at 03.50 hours on 7^th June 2007;

(b) the cause of her death was ischaemic and valvular heart disease;

(c) there were no reasonable precautions whereby her death might have been avoided;

(d) there were no defects in any system of working which contributed to her death; and

(e) there were and are no other facts which are relevant to the circumstances of her death.

 

 

 

 

 

 

 

NOTE

 

Introduction

[1] This fatal accident inquiry ("the Inquiry") has been convened to inquire into the circumstances of the death of Mildred Rosenshine ("Mrs Rosenshine") which occurred on 7^th June 2007 within the Victoria Infirmary, Glasgow G42 9TY ("the Victoria"). She was then 82 years of age, having been born on 8^th February 1925. She resided latterly at 70 Crookfur Cottages, Crookfur Road, Newton Mearns, G77 6JY.

 

[2] The Crown applied to the Court for the holding of the Inquiry because at the time of her death Mrs Rosenshine was an in-patient within the Victoria and the Lord Advocate has considered it expedient in the public interest to hold it. It has therefore proceeded under section 1(1)(b) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 ("the Act").

 

[3] The Inquiry has concerned itself with the events in the life of Mrs Rosenshine from the late afternoon of 6^th June 2007, when her medical general practitioner took the decision to have her admitted to the Victoria, where she was admitted to Ward 17 ("the Ward") by way of the Accident and Emergency Department, until 03.50 hours on 7^th June 2007 when, while still in the Ward, she was pronounced dead, a period of slightly less than twelve hours in duration. Following the subsequent post mortem her cause of death was reported to the Procurator Fiscal as being, and was registered as being, ischaemic and valvular heart disease.

 

The conduct of the Inquiry

[4] At the Inquiry the Crown were represented by Mr Bonnar, procurator fiscal depute, Glasgow, the Greater Glasgow Health Board, who carry responsibility for the running of the Victoria and for the actions of its staff, by Miss Galbraith, advocate, and the family of Mrs Rosenshine by her son, Mr Raymond Rose.

 

[5] In the course of the Inquiry the Crown led the evidence of 11 witnesses: -

 

1.      Mr Raymond Rose, the son of Mrs Rosenshine.

2.      Doctor Stephen Goldberg, her medical general practitioner.

3.      Doctor Deborah Whitters, who was on duty on 6^th June 2007 in the Victoria as a receiving physician and who took a telephone call about her from Doctor Goldberg.

4.      Doctor Omar Hassan, who was also on duty during the evening of 6^th June in the Victoria as a receiving physician who examined her, took the decision to place her in the Ward and compiled her management plan.

5.      Nurse Wilma McRae, who was on duty in the Accident and Emergency Department of the Victoria on 6^th June until 19.30 hours.

6.      Staff Nurse Sarah, known as Sally, Porter, who was on duty in the Ward throughout the night of 6^th/7^th June and was the nurse in charge of the Ward that night.

7.      Staff Nurse Marjory Donachie, who was also on duty in the Ward throughout the night of 6^th /7^th June.

8.      Doctor Russell Allan, who was on duty as a junior house officer in the Victoria throughout the night of 6^th /7^th June and who was called to assist in the attempts to resuscitate Mrs Rosenshine.

9.      Doctor Robert Ainsworth, a consultant forensic pathologist within Glasgow University who conducted the post mortem on Mrs Rosenshine on 8^th June and subsequently prepared a post mortem report on his findings dated 12^th June, Crown production number 1, and was the certifying registered medical practitioner who registered her death on 8^th June and intimated that to the Procurator Fiscal, a copy of which intimation is Crown production number 2.

10.  Mr Neil Nichol, a consultant in Emergency Medicine in Ninewells Hospital, Dundee, who was called to give evidence as a skilled witness and who had prepared two reports on the circumstances of her death, the earlier, which was Crown production number 5, before he had seen the post mortem report, and the later, Crown production number 6, after he had seen it.

11.  Mrs Julie McQueen, a clinical risk manager based at Glasgow Royal Infirmary who had investigated the circumstances of the death of Mrs Rosenshine from the standpoint of its clinical aspects and produced a Root Cause Analysis Investigation Report ("the RCA") into those aspects which was Crown production number 7.

Neither the Health Board nor the family called any witnesses.

 

[6] All three parties represented at the Inquiry prepared written submissions which are lodged in process. Each then spoke to their submissions and had the opportunity to comment on those of the others as they thought right. In fact only counsel made any such comment. Both the Crown and the Health Board invited me to make findings under section 6(1)(a) and (b) that were in conformity with the contents of the intimation of the death of Mrs Rosenshine to the Procurator Fiscal and the cause of death given in the post mortem report, and beyond that to make what are commonly known as formal findings for the remaining three criteria in section 6(1).

 

[7] The family made no mention of section 6(1)(a) or proposal as to cause of death under section 6(1)(b) and what they did say could be said to fall most readily under 6(1)(d) and (e) and possibly (c). They voiced five concerns, all relating to the standard of care within the Victoria. As expressed they are as follows.

1. "Are we to deny patients who have terminal illness care, because, they "would die anyway"?"
2. The individual failings of members of staff "were magnified and cumulatively caused a catastrophe, because those persons were let down by a system and structure that was inherently flawed."
3. The admission of Mrs Rosenshine "who needed more intensive monitoring to a side room at the Victoria Infirmary, exposes a serious flaw in the admissions procedures" which "was driven in part by an inability to properly prioritise the care required, but more importantly by the lack of isolation facilities within the receiving medical wards at the Victoria."
4. Despite going through the complaints procedure and months of meetings, the Root Cause Analysis was never made available to the family and "[s]urely, if it had, it would have gone some way to reassuring us that something was being done?"
5. "From the evidence it [was] not clear, despite claims in the RCA report, that an escalation policy was available to those staff who were concerned about the admission, nor how they would access it. This is a failing in the management structure, at present, which does not focus on site management, i.e. individual hospitals, but on large geographical areas. This means individual staff end up uncertain about who to contact, when they have concerns."

I do not propose to précis the submissions here any further, but I will refer to their contents where that is appropriate.

 

[8] The productions used in the Inquiry were all lodged by the Crown. There were ten, and all consisted of more than one page. As presented, the bundle of productions was numbered consecutively throughout all ten like a book, from page 1 to page 204, rather than each production being numbered individually. All parties were content to work with page numbers only and for ease of reference I will do the same when I refer to a production in this Note from now on. All dates given are in 2007 unless otherwise indicated.

 

The function and purpose of a fatal accident inquiry

[9] All Fatal Accident Inquiries are brought under, and are governed by the provisions of, the Act. It imposes duties on the Lord Advocate, the procurator fiscal for the district with which the circumstances of the death in question appear to be most closely connected and the sheriff to whom application is made for holding an Inquiry. It also makes provision for making rules that govern procedure and the payment of fees, and the procedural rules currently in force are the Fatal Accidents and Sudden Deaths Inquiry Procedure (Scotland) Rules 1977.

 

[10] The primary duty on the sheriff is that enjoined by section 6(1) of the Act: to issue a determination at or as soon as possible after the conclusion of the evidence and any submissions thereon setting out the circumstances of the death in question by reference to the five criteria listed in that subsection so far as they have been established to his satisfaction. Those five are: -

(a) where and when the death and any accident resulting in the death took place;

(b) the cause or causes of such death and any accident resulting in the death;

(c) the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided;

(d) the defects, if any, in any system of working which contributed to the death or any accident resulting in the death; and

(e) any other facts which are relevant to the circumstances of the death.

The scope of all fatal accident inquiries is determined, delineated and circumscribed by this subsection. After the conclusion of the evidence and the submissions thereon I indicated to parties what my Determination would say on each of those five criteria, but in addition to that I have to present it in writing.

 

[11] The function of the sheriff at a Fatal Accident Inquiry in making his Determination does not include making any finding of fault or apportioning blame between any persons who might have contributed to the accident. The Act does not empower the sheriff to do that. This was authoritatively stated in the case of Black v Scott Lithgow Limited 1990 SC 322; 1990 SLT 612 in which Lord President Hope, in his opinion, took the opportunity to state the function of the sheriff in the following terms: -

"There is no power in this section to make a finding as to fault or to apportion blame between any persons who might have contributed to the accident. ... It is plain that the function of the sheriff at a fatal accident inquiry is different from that which he is required to perform at a proof in a civil action to recover damages. His examination and analysis of the evidence is conducted with a view only to setting out in his determination the circumstances to which the subsection refers, insofar as this can be done to his satisfaction. He has before him no record or other written pleading, there is no claim or damages by anyone and there are no grounds of fault upon which his decision is required. The inquiry is normally held within a relatively short time after the accident ...It provides the first opportunity to canvass matters relating to precautions which might have avoided the death or any defects in any system of working which contributed to it, at a stage when these issues have not been clearly focused by the parties to any future litigation which may arise. And it is not uncommon ... to find questions being asked about possible precautions or defects which are not the subject of averment in the subsequent action of damages." (page 327 and 615G to H)

 

[12] As Lord President Hamilton observed in the recent case of Global Santa Fe Drilling v Lord Advocate 2009 SLT 597 under reference to Black "[a] fatal accident inquiry is a statutory procedure" .. and "[a]lthough the sheriff presiding at it has judicial duties ...he does not sit to determine the rights or obligations of parties" (paragraph [28] at p 604). It is a fact finding inquiry not a fault finding inquiry. It is inquisitorial in form rather than adversarial. The standard of proof of the circumstances of the death is on the balance of probabilities. The onus of proof rests on the Crown because, by virtue of section 1 of the Act, the duty of investigating the circumstances of the death in question lies on the Crown.

 

[13] The word "accident" is not defined in the Act. Various views have been expressed as to its meaning and scope. In his Determination following an Inquiry into the death of Alexander Cusker, dated 16 December 2008, Sheriff J K Mitchell, sitting at Glasgow Sheriff Court, expressed the following views:

"[4] In Mr. I H B Carmichael's Sudden Deaths & Fatal Accident Inquiries, third edition, at paragraph 5.69, the learned author states:- 'Accidents can occur anywhere and in almost any context...If a patient died...as the result of an error which occurred in a...therapeutic procedure, that death results from an 'accident'. I respectfully accept the learned author's approach to and interpretation of the term 'accident' as it is used in the 1976 Act. In its common usage, an 'accident' is 'an unfortunate incident that happens unexpectedly and unintentionally, typically resulting in damage or injury': see the New Oxford Dictionary of English."

I respectfully adopt and follow that approach.

 

[14] Any Fatal Accident Inquiry is a particular, rather than a general, inquiry in two respects: as mentioned above, it is governed by the whole terms of the Act and in particular the requirements of section 6 which prescribe what the Determination has to deal with; and it is circumscribed by the evidence led in the course of the inquiry. There may be issues that are considered to be germane to the death in question but unless they are capable of falling within the statutory provisions and are discussed appropriately in the evidence then they cannot be included in the Determination.

 

My assessment of the evidence led at the Inquiry

[15] My first task in preparing my Determination is to assess how I deal with the evidence led by all the witnesses. My assessment of all the evidence led is that I am satisfied I can rely upon it all. All the witnesses to fact were clearly doing their best to recall as accurately as they could the events of almost exactly three years ago. They did so candidly and without reserve and even when an occasional answer betrayed the use of hindsight, that did not compromise the reliability of that evidence. When the evidence of them all is put together it produces a unified and comprehensive picture of relevant events, decisions and actions. With one very limited exception all cross-examination was on behalf of the Health Board, and all concentrated on seeking further clarification of matters raised in examination-in-chief rather than putting a different or contradictory position to the witness.

 

[16] I was particularly impressed by the evidence of Staff Nurse Porter. She was a highly experienced nurse. She had been an enrolled nurse since 1984 and a registered nurse since 1990. She struck me from what she said and also how she said it that I could place complete reliance on her evidence when it comes to determining the sequence of relevant events, the decisions made and the actions taken by her and her staff while Mrs Rosenshine was in the Ward. She was supported in all material respects in what she said by Staff Nurse Donachie, the other member of the nursing staff on duty with her that night, where their evidence on events overlapped. Staff Nurse Donachie had over ten years more experience of nursing than Staff Nurse Porter and I formed a similar impression of the quality of her evidence and the extent to which I could rely upon it.

 

[17] I accept without qualification the evidence of Dr Ainsworth regarding his conduct of the post mortem, his findings and his conclusions with one small exception. In his post mortem report he observed that "the development of significant cardiac arrhythmias in relation to abnormal blood potassium levels typically only associated with a high blood potassium (hyperkalaemia)" (page 4). Mr Nichol disagreed with that statement on the ground that "[i]t is true that high levels are more likely to produce arrhythmias, but it is well recognized that abnormally low levels also predispose to arrhythmia" (page 186). I prefer the evidence of Mr Nichol on this matter on the ground of his much greater experience of this particular field of work.

 

[18] Mr Nichol was called as an expert in emergency medicine. His impressive professional career and extensive experience in emergency medicine gave him the right to speak with great authority on the circumstances of the death of Mrs Rosenshine. I accept his evidence as authoritative, adopt his conclusions gratefully and apply them in making my determination.

 

[19] There is only one feature of the evidence led on the facts where there was the potential for a dispute and that was between Staff Nurse Porter and Dr Hassan over the whereabouts of the Fluid and Additive Medicine Prescription Sheet ("FAMP Sheet"), which was at page 142, prior to about 23.15 hours on 6^th June. It was that potential that led to Doctor Hassan being recalled to give further evidence on that matter. In light of all the evidence given by both witnesses I conclude that their evidence can be reconciled without questioning the reliability of either.

 

My findings

[20] In light of my assessment of the evidence led and of the content of the submissions I am satisfied to the required legal standard of proof that I can make a narrative of events that I consider to be significant and that the facts in that narrative entitle me to make the Determination that precedes this Note for each of the five criteria set out in section 6(1) of the Act.

 

The narrative of events

[21] Mildred Rosenshine was born on 8^th February 1925. She resided latterly at 70 Crookfur Cottages, Crookfur Road, Newton Mearns G77 6JY which was sheltered accommodation. Her children included Raymond Rose. She was an active lady who did her own shopping and went to concerts. She suffered from hypertension which had first been diagnosed in 1997, for which she had been repeatedly prescribed Bendroflumethiazide and Doxazosin (page 77), and from irritable bowel syndrome, first diagnosed in October 1999 but said to be a condition from which she had then suffered for more than three years (page 102).

 

[22] It was in the late afternoon of 6^th June that Doctor Goldberg took the decision to have Mrs Rosenshine admitted to the Victoria because it was then that he received the results of blood tests for her that showed that her potassium level was standing at 1.8. He was aware that she had been suffering from diarrhoea for some eight days. She had consulted him about that on 31^st May by telephone and he had noted then to review her case if that were not settling. He had paid her a house call on 4^th June and found that she was still suffering from that condition and by then had been for six days. She had sought to make light of it in saying that she was getting better. To address her condition he had prescribed Lomotil for her. Two days later he had paid her a further house call and had found that her condition remained the same. She had complained of dizziness. He had checked her blood and sent a sample of it to the Victoria.

 

[23] While acknowledging that he was not an expert in the dangers that a low potassium reading might pose, he understood that a normal reading for potassium in the blood lay in the range of 3.5 to 5.00 and that a reading of 1.8 was potentially dangerous and needed hospital treatment. Having said that he was aware that the records showed readings of 2.9 and 2.8 on 14^th May and 29^th May respectively, neither of which was within the normal range, but neither had led to the expression of any concern that it required urgent treatment.

 

[24] On receipt of the blood test results Doctor Goldberg made two telephone calls, one to Mrs Rosenshine telling her the results and his decision that she needed to go into hospital and the other to the Victoria. He spoke to Doctor Whitters, one of the receiving physicians on duty and gave her details of the blood results. Rather than spend time returning to her house with an admissions letter for her to hand to the receiving physician, he telefaxed such a letter from his surgery to the Victoria for the attention of that physician (page 76). He arranged for Mrs Rosenshine to be conveyed to the Victoria by ambulance. That ended his direct participation in the care of Mrs Rosenshine that day.

 

[25] Doctor Whitters understood from her discussion with Doctor Goldberg that the primary reason for admission related to the low potassium reading. She wrote up the blood test results in the Unified Case Record (UCR) for Mrs Rosenshine (page 157) which she took not from the letter but from the computer system. She took no further part in the care of Mrs Rosenshine. She did not see the letter from Doctor Goldberg. She did not see Mrs Rosenshine when she was admitted.

 

[26] The first feature of Mrs Rosenshine's condition that Doctor Goldberg's letter mentioned was that she had suffering from diarrhoea for over one week. It mentioned her potassium reading of 1.8 in its third line without making any comment on it.

 

[27] The ambulance was summoned at 17.35 hours to attend to Mrs Rosenshine and arrived at her home at 18.11 hours, as confirmed by the Scottish Ambulance Service Patient Report Form (page 145). The ambulance crew noted as her history: 'GP referral: patient feeling generally unwell over past fortnight. Diarrhoea over last nine days. Hx [history] hypoKalaemia. No letter left by GP'. Their examination findings at 18.20 hours were that she was fully alert, had a pulse of 107, a respiratory rate of 18 and blood pressure of 128/78. The ambulance crew made no interventions and transported her to the Victoria, arriving there at 18.43 hours. Their Report Form makes no mention of low potassium.

[28] On arrival at the Victoria she was seen and assessed by Staff Nurse Lindy Morrison, at the request of Nurse Wilma McRae. Her nursing observations, from the standardised early warning scoring system (pages 140 and 141), show that she was seen at 18.57 hours. Her presenting complaint was given as diarrhoea, her respiratory rate as 18, her oxygen saturations on air as 97%, her blood pressure as 147/69, her heart rate as 92 and that she was alert. Her temperature was very slightly low at 35.9 degrees. Her blood glucose was measured as being 7.2. Her score was given as one which meant that she was well. An ECG was performed at 19.08 hours. The printout of it is at page 147. The procedure showed normal sinus rhythm with a left bundle branch pattern intraventricular block.

 

[29] Doctor Hassan was on duty and on call as a receiving physician from 19.00 hours to midnight on 6^th June. He was then a medical senior house officer at the Victoria with some four years' clinical experience and at the time was working on his cardiac rotation. His first involvement with Mrs Rosenshine came at about 19.20 hours when he read her case notes in the Accident and Emergency Department. From them he took that her presenting complaint was diarrhoea for a few days and that she was also suffering from a low Potassium level. She presented as a regular general practitioner referral because she was not marked as being a medical emergency or a high priority admission.

 

[30] Doctor Hassan examined Mrs Rosenshine in the Accident and Emergency Department, took a blood sample from her and sent it off for analysis. Immediately afterwards he wrote up his record of his examination in the UCR (pages 152 to 155) at about 19.45 hours. He listed her presenting complaint as: '1. Diarrhoea, vomit; 2. K+ decreased' (page 148). He then narrated the history of her presenting complaint as: "82 year old woman with a history of IBS [irritable bowel syndrome]. Generalised colicky abd [abdominal] pain plus diarrhoea for 8 days + nausea but no vomiting. Feel[s] lethargic, poor oral intake. Passing 1-2 motions/day watery. GP checked blood today and found [low] K [Potassium]." He gave her past medical history as: 1. Irritable bowel syndrome. 2. Hypertension. He listed her medication as being: Doxazosin and Bendrofluazide, both of which are anti-hypertensives; Mometasone ointment, a steroid preparation; Omeprazole, prescribed to reduce gastric acidity and Loperamide which she had been given by her general practitioner that day and was used in the treatment of diarrhoea. All this information he gained from her. His general examination findings then documented essentially normal vital signs. Her cardiovascular system examination was essentially normal other than an ejection systolic murmur (ESM) to which he added that it was likely due to aortic stenosis. The abdominal examination was normal as was the reading of 15 on the Glasgow Coma Score. Chest and abdominal x-rays were undertaken and no abnormality was noted. The interpretation of the ECG as showing a normal sinus rhythm with partial left bundle branch block was not in his handwriting and he did not know whose it was. He listed his impression and differential diagnosis as: "Diarrhoea likely secondary to IBS → hypokalaemia. Need to exclude infection'.

 

[31] His management plan lists the following under the heading 'DME' (Department of Medicine for the Elderly).

1. Admission (unlikely infective however consider side room until stool culture negative).

2. BL [bloods].

3. Chest x-ray + ECG + abdominal x-ray.

4. IV fluid 4 hourly + K supplement (according to K level).

5. Stool for culture and sensitivity.'

 

[32] Doctor Hassan's assessment was that she did not present as an emergency but required immediate treatment but not admission to a high dependency ward. Her low potassium level he considered would be addressed by the intravenous fluid with potassium supplement but not to be administered as quickly as would require her to have a cardiac monitor.

 

[33] His diagnosis meant that he had to consider the distinct possibility that she could transmit bacterial infection to other patients and to staff. He was aware of the NHS Greater Glasgow Control of Infection Committee Policy (Crown production 8, pages 195 to 198) that was then in force ("the loose stools policy"). It directed health care workers to follow the policy. Doctor Hassan fell within that category. Its purpose was to minimise the risk of an outbreak of infection caused by loose stools that contained infectious diarrhoea. Inter alia it assessed the very old as extremely susceptible to the risk of infection. The policy directed that a precaution to take when a patient presented with loose stools that could contaminate the environment was to place that patient in a single room. Mrs Rosenshine fell into that category. Only if a patient were clinically unsuitable for isolation would a risk assessment have to be undertaken by the clinical team in conjunction with a member of the Infection Control Team. The assessment of Mrs Rosenshine in light of the reason for her presentation and her own observations to Doctor Hassan did not take her within the category of being clinically unsuitable for isolation in a single room. She was stable and comfortable.

 

[34] While still in the Accident and Emergency Department, Doctor Hassan made an entry in the FAMP Sheet as entry N of a prescription of normal Saline 0.9% 500 millilitres with an additional Potassium Chloride doze of 20 millimoles to run intravenously over 4 hours.

 

[35] Doctor Hassan arranged for her admission to the Ward. That was not his first ward of choice. He had contemplated placing her in either Ward 12A or 14 but neither ward had a single room available that would secure compliance with the loose stools policy, and the Ward did. The Ward treated patients who suffered from conditions that involved gastro-enterology, cardiology and the care of the elderly. In that respect it was well suited to receive her and care for her.

 

[36] On concluding writing up the notes for Mrs Rosenshine Doctor Hassan returned them to the case note rack. He did not follow his normal practice of speaking to a nurse to give oral instructions about what he had prescribed for her, because at the time he did not find a nurse to tell her. To have spoken to a nurse in that situation for that purpose was best practice. Instead, he prioritised seeing other patients brought into the Accident and Emergency Department over looking for a nurse for that purpose. He was satisfied that Mrs Rosenshine would have been treated urgently and his prescription followed up within the Accident and Emergency Department when the case notes were retrieved from the rack or at the latest on Mrs Rosenshine's admission to the ward.

 

[37] Staff Nurse Porter was alerted to the impending admission of Mrs Rosenshine to the Ward by a staff nurse in the Accident and Emergency Department who said that she was suffering from sickness and diarrhoea and that she was to be housed in the ward's only single room as a precaution. There was no discussion of the treatment that she needed and no mention of any other condition. The focus of discussion was on the suitability or otherwise of treating her in a single room.

 

[38] Mrs Rosenshine arrived on the Ward at about 21.00 hours accompanied by her son Mr Raymond Rose. She was sitting up on a trolley, had good colour and was alert and orientated and able to converse with Staff Nurse Porter. She did not complain of being in any pain at all. She was able to stand unaided and walked from the trolley to the bed in the single room. Once Mrs Rosenshine was settled in that room, Staff Nurse Porter left her and took her notes with her.

 

[39] At about this time she received a telephone call from the biochemistry ward giving the electrolyte results for Mrs Rosenshine, and she recorded them in the notes, timing them at 21.00 hours (at page 157). In particular the Potassium reading was 2.1. That reading concerned Staff Nurse Porter. She telephoned for the doctor who was on call and covering the ward to authorise treatment for that low reading by way of intravenous drip because she was not so authorised. That unnamed doctor, not Doctor Hassan, telephoned her back to say that he (or she) would come to the ward as soon as was practicable because he (or she) was attending to another patient.

 

[40] Staff Nurse Porter read through all the available notes for Mrs Rosenshine within half an hour of her admission to the Ward. While doing that she did not come upon the FAMP Sheet.

 

[41] The nursing notes for the Ward (at page 158) are not timed. They state: "Patient was an emergency admission via A & E. On presenting herself to Ward 17, she appeared settled, no evidence of diarrhoea or vomiting today, stool sample for C & S [culture and sensitivity] to be obtained. Commenced on IV fluids + K+ 20 mmol. K+2.1. CRP 92. Son with patient on admission. ECG carried out sinus rhythm.' That commencement is timed in the FAMP Sheet at 23.50 hours.

 

[42] The commencement at that time came about because Doctor Hassan went to the Ward at 23.15 hours to check that Mrs Rosenshine was receiving the treatment that he had prescribed. He found that she was not. He consulted her notes in the duty room of the ward. He found amongst them the results of the test of the blood sample taken from her in the Accident and Emergency Department and in particular saw that her potassium level had risen to 2.1. After spending some ten minutes in the duty room, he gave the FAMP Sheet to Staff Nurse Porter and instructed the nursing staff on the ward to commence her treatment immediately. He added to the FAMP Sheet as entry O a request for a second prescription of 500 millilitres of Saline fluid with added Potassium, to be administered intravenously over four hours. Having done that, he left the ward at about 23.45 hours as the nursing staff were preparing to administer the fluid. That concluded his direct participation in the care of Mrs Rosenshine.

 

[43] The intravenous infusion having commenced, Mrs Rosenshine's condition was monitored regularly. At 02.00 hours on 7^th June Mrs Rosenshine was seen to be settled and stable. She was not suffering from shortness of breath. She gave no indication that she was reacting adversely to the infusion or that she needed medical intervention. Nothing in her condition gave Staff Nurse Porter any cause to be concerned for her welfare.

 

[44] Shortly before 03.00 hours Mrs Rosenshine was assisted by a nursing auxiliary to use the commode. She made no complaints of pain, appeared satisfactory and chatted to the staff member who had assisted her. She was returned to bed and settled.

 

[45] At 0315 hours on 7^th June Staff Nurse Donachie heard Mrs Rosenshine sigh. She went into the side room to check on her and found her upright in bed but slumped onto her right side, unresponsive, cyanosed, with no palpable pulse and barely breathing. Her intravenous infusion was still in place. Staff Nurse Donachie's immediate impression was that Mrs Rosenshine had suffered some sort of cardiac event, gauged her situation as an emergency, and shouted out that a cardiac arrest call be made and that the emergency resuscitation trolley be brought. Staff Nurse Porter made that call at 0315 hours and brought that trolley by which time Staff Nurse Donachie had commenced CPR assisted by Nurse Lynn Wright. Staff Nurse Porter assisted them. In particular she arranged for the administration of oxygen to Mrs Rosenshine.

 

[46] The cardiac arrest team arrived promptly. It consisted of two doctors and an anaesthetist. One of the doctors was Doctor Allan. The team assessed that Mrs Rosenshine was in full cardiac arrest. They ascertained that she had a shockable rhythm and therefore administered three shocks to her but this was unsuccessful in restarting her heart. After the third attempt she was noted as being in a condition of pulseless electrical activity which, unlike her previous condition of ventricular fibrillation, is a non-shockable rhythm. The team continued with repeated attempts at resuscitation. Alongside that, at the request of the anaesthetist, Staff Nurse Donachie administered rapidly on two occasions 500 millilitres of normal Saline with 40 millimoles of additional Potassium Chloride as narrated in the FAMP Sheet (page 142) as entries Q and R. She also took a blood sample from her.

 

[47] Despite these further attempts at resuscitation, she remained in a state of pulseless electrical activity. The team took the decision to bring their attempts to an end and she was pronounced dead at 0350 hours.

 

[48] The results of the blood sample taken during the attempts at resuscitation included a finding that her Potassium level had risen to 2.6.

 

[49] At the post mortem examination of Mrs Rosenshine conducted on 8^th June 2007 Doctor Ainsworth discovered evidence of significant heart disease. As he described it in his report (Crown production number 1, at page 3): "There was severe atheroma and calcification at the origin of the right coronary artery resulting in almost complete occlusion of the vessel at this point, whilst the other major coronary arteries were mildly atheromatous and extensively calcified. The aortic valve was severely calcified and stenosed resulting in significant narrowing of the valve aperture." He also noted that microscopy of her heart also revealed evidence of previous ischaemic damage and of hypertrophic change within some mycocytes. He concluded from his findings that Mrs Rosenshine suffered from significant heart disease in the form of both severe ischaemic and valvular heart disease, and that her death occurred most likely secondary to a cardiac arrhythmia. He saw this as explaining her sudden collapse whilst in hospital and he observed that her degree of heart disease was such that she could have collapsed at any time (page 4). He gave as her cause of death ischaemic and valvular heart disease. He repeated that when registering her death with the Registrar for the District of East Renfrewshire at Glasgow as certifying registered medical practitioner on 12^th June 2007. That registered death certificate was sent to the Procurator Fiscal of Glasgow and the intimation form dated 22^nd July 2007 was Crown production number 2 (page 6).

 

[50] In October 2007 Mrs McQueen, in her capacity as a clinical risk manager, was asked to compile the RCA into the death of Mrs Rosenshine. In order to compile it she worked with one other as a core team and with two main contributors. The RCA focused on the clinical aspects of her death. Having carried out the required analysis, which included information and statements obtained during the investigations into the complaint preferred by the family of Mrs Rosenshine and interviewing medical and nursing staff involved in treating her, she made 7 recommendations. So far as relevant to the Inquiry they concerned issues of clinical practice and procedure. The RCA did not identify any systemic failures. Instead it sought to strengthen existing standards and practices.

 

[51] Mrs McQueen submitted the RCA to a management team which thereafter produced an Action Plan whose actions were all based on the recommendations. A copy of that Action Plan is Crown production number 10 (pages 200 to 204).

The five criteria

Section 6(1)(a) : Where and when her death took place

[52] The evidence to support the time and place of her death came from Staff Nurse Porter, Staff Nurse Donachie, Doctor Allan, and Doctor Ainsworth. None of that evidence was questioned. The time is given in both Doctor Allan's notes and the note drafted by Staff Nurse Donachie before she went off shift that morning (page 146). It was adopted by Doctor Ainsworth without demur and appears in both his post mortem report dated 12^th June 2007 and the death certificate for her which he registered that same day.

 

Section 6(1)(b) : The cause of her death

[53] The evidence to support the cause of death came from the same sources as for section 6(1)(a) above and also from Mr Nichol. It was unchallenged in any way at all. Mr Nichol, once he had been made aware of the post mortem report, accepted Doctor Ainsworth's cause of death and opined in his supplementary report, Crown production number 6 at pages 186 and 187, that the almost complete occlusion of the right coronary artery was of great significance and would predispose Mrs Rosenshine to sudden cardiac death due to cardiac dysrhythmia, which could have occurred at any time (page 186). He adopted this opinion in the course of his oral evidence without any additional comment or qualification. The medical assessment of the cause of death was borne out by the actions and responses of those who sought to resuscitate her between 0315 hours and 0350 hours on 7^th June which were entirely consistent with it. This cause of death was unknown and undiagnosed at the time of her admission. It appears nowhere in the medical records that were put in evidence at the Inquiry. Doctor Goldberg said in evidence that he had treated her since 1991 and he was unaware that she suffered from ischaemic heart disease. At no time was it suggested in examination-in-chief or in cross examination that the true but unknown condition of her heart was something that ought to have been known to the staff of the Victoria or diagnosed by them on her admission on 6^th June. I am satisfied that the evidence before the Inquiry enables me to go no further than to say that the nature and extent of her significant heart disease was unknown at the time of her death and was not something that ought to have been known by or to those treating her in the Victoria.

 

Section 6(1)(c) : The reasonable precautions, if any, whereby her death might have been avoided

[54] On the evidence there were no reasonable precautions whereby her death might have been avoided, given her cause of death and the fact that at the time her heart condition was unknown and was not something that ought to have been known to the staff in the Victoria. Doctor Ainsworth opined that the degree of heart disease present was such that she could have collapsed at any time (page 4) and Mr Nichol, having seen the post mortem report concurred in saying that sudden cardiac death could have occurred at any time (page 186). As a consequence in so far as the third expressed concern of the family might be said to suggest that a reasonable precaution would have been to place her not in a side room in the Ward but in an isolation facility in a receiving medical ward, there is no evidence to support that. The evidence that was presented by Mr Nichol, and which I accept, was to the effect that even if she had been placed in a high dependency unit or in a coronary care setting, that would not have increased her chances of being resuscitated successfully because of the degree of occlusion within her coronary artery and extent of the narrowing of her aortic valve (pages 186 and 187).

 

[55] Moreover if the family's third concern under this criterion extends to encompassing the delay in commencing Mrs Rosenshine on an intravenous infusion of saline solution with added Potassium Chloride, and Mr Rose raised this in the course of his evidence, then again the evidence which I accept is to the effect that that delay did not contribute to the circumstances of her death. In his original report Mr Nichol drew particular attention to the need for her to receive such an intravenous infusion but in his supplementary report he opined that her admittedly very low Potassium level on admission did not contribute to her death which could have occurred at any time irrespective of the Potassium level (page 186). That there was a delay in starting the infusion was readily admitted. It was neither wished nor sought. It simply occurred in the overall circumstances that prevailed on that evening in that busy hospital and that despite the best endeavours of Staff Nurse Porter who commendably but unsuccessfully sought shortly after 21.00 hours to arrange for such an infusion independently of the direction of Doctor Hassan of which she was unaware at the time she did that. Mrs Rosenshine was not started on the drip until 23.50 hours, some four hours after Doctor Hassan decided on her management plan, and slightly less than three hours after she was admitted to the Ward.

 

Section 6(1)(d) : The defects, if any, in any system of working which contributed to her death

[56] On the evidence there were no defects in any system of work which could be said to have contributed to Mrs Rosenshine's death. The second, third and fifth of the family's concerns assert failings in the system of care that was in force at the Victoria at the time of her death: the second that there were individual failings of members of staff which were magnified and cumulatively caused what is described as a catastrophe because "the system and structure" was inherently flawed; the third that there was a serious flaw in the admissions procedures ultimately due to a lack of isolation facilities within the receiving medical wards at the Victoria "driven in part by an inability to properly prioritise the care required" by Mrs Rosenshine who is described as needing "more intensive monitoring" than was available in a side room; and the fifth that there was a failure in the management structure because it did not focus on individual hospitals but on "large geographical groups".

 

[57] The second concern does not indicate whose failings are being placed in issue. I assume that the system referred to is the clinical system. The stated concern does not make it clear what it was about that system that was inherently flawed and moreover what is meant by "structure" in this context. I infer that the family perceive the failings relate to the four features of the care of Mrs Rosenshine that Mr Rose in essence gave in evidence under cross-examination by counsel: the decision to admit her to the Ward rather than to a high dependency unit; the decision to admit her to the side room of that ward; the application of the loose stools policy; and the delay in commencing her intravenous infusion of saline solution with additional Potassium. The simple and decisive answer to all of these perceived failings is that the evidence before the Inquiry for the true cause of her death indicates that none of these contributed to it. Here I rely upon the conclusions of Mr Nichol which I accept. In his supplementary report he said that sudden cardiac death could have occurred at any time, irrespective of the potassium level and he followed that by saying that even if that cardiac arrest had occurred in a high dependency unit or in the coronary care setting he would not expect resuscitation to be successful, because of firstly the almost completely occluded coronary artery and secondly the narrowed aortic valve (at pages 186 and 187).

 

[58] He concluded his supplementary opinion by saying that he remained of the view that there were examples of poor care in the management of Mrs Rosenshine but that in light of the findings made at the post-mortem he did not think that these deficiencies altered the outcome (page 187). In his evidence he instanced in particular the failure on the part of Doctor Hassan to speak to nursing staff once he had prepared his management plan and tell them that Mrs Rosenshine should be started on an intravenous drip with added Potassium. In fairness to Doctor Hassan he accepted unquestioningly that best practice would have been to have done that, but explained that in the circumstances that obtained in the Accident and Emergency Department on that evening he prioritised seeing another patient over seeking out a nurse to tell her that and felt confident that the nursing staff on duty would have picked up the notes for Mrs Rosenshine and arranged for her to be treated urgently. That is at least understandable when seen in the context of a busy department. In the event the failure to transmit orally to nursing staff the need to start Mrs Rosenshine on that drip did not contribute to the circumstances of her death.

 

[59] The decision to admit Mrs Rosenshine to the Ward and have her accommodated within its single room was taken in conformity with the loose stools policy then in force throughout NHS Greater Glasgow, which included the Victoria. It was Doctor Hassan who made the decision to follow the policy. He was obliged to do so if Mrs Rosenshine's presenting complaint brought her within the category of patient covered by the policy. It did. She was not clinically unsuitable for isolation. A single room was available in the Ward. On the information then available to Doctor Hassan it cannot be said that his decision to have Mrs Rosenshine admitted to the side room in the Ward was an incorrect exercise of his professional judgement. I am reinforced in that conclusion by the fact that Mr Nichol did not criticise this decision in either of his reports. Indeed when he was asked about the policy in the course of his evidence he agreed with the suggestion that it accorded with the policy in force at the hospital where he practised.

[60] As far as the clinical system then in operation within the Victoria is concerned, what I can derive from the evidence is that there was nothing put in issue that could found the contention that that system was inherently flawed. Mrs McQueen said in the course of cross-examination by counsel that in preparing her RCA she had not identified any systemic failures. She was not further cross-examined or re-examined on that by any of the interested parties. I accept that evidence as a correct conclusion. She was an experienced clinical risk manager, and she applied that experience in her extensive investigations into the clinical aspects of the death of Mrs Rosenshine.

 

[61] In the third concern of the family there is reference to Mrs Rosenshine needing "more intensive monitoring". Quite what and why is not explained. I have already indicated that I concluded on the evidence led that the decision to admit her to a side room in the Ward was not open to criticism given her presenting complaint. The staff on duty in the ward explained where in the ward that room was situated. I am satisfied that that evidence established that Mrs Rosenshine was able to receive the same level of care and attention as she would have expected to receive had she been in the main part of the ward. She did not suffer in that respect from a deficit of care. The staff were able to monitor her drip, to respond to her needs when required and to monitor her quickly when required, all as demonstrated in the nursing notes and in particular by their immediate response to her cardiac arrest. If by "more intensive monitoring" the family means that she ought to have been provided with a cardiac monitor because of her low Potassium level, then the evidence of Doctor Hassan was to the effect that while it was common to use one in that situation it was not a prerequisite and not a requirement that all such patients be fitted with one. In addition he pointed out that he was aware that the speed at which he directed she receive the intravenous infusion was slower than would require the use of a cardiac monitor. That she was not fitted with a cardiac monitor was a clinical judgement that he took. Whether that was a poor decision or not, and I am not in a position to give a view on that, in the last analysis the absence of a cardiac monitor did not play any part in the circumstances of her death.

 

[62] As for the reference to a structure, if by that is meant the management structure then that concern is expressed with a degree of specification in the fifth concern of the family. Whether or not the management structure focused on large geographical areas rather than on individual hospitals would only fall within the scope of the Inquiry if that impacted upon the circumstances of the death of Mrs Rosenshine. In this regard I recall what I said much earlier in this Note about the Inquiry being a particular inquiry rather than a general one. Conscious of that statutorily imposed limitation I have to say that there is no evidence to substantiate where the focus properly lay nor is there any to demonstrate or even suggest that whatever the focus truly was at the material time it contributed in any recognisable and direct way to the circumstances of the death of Mrs Rosenshine.

 

Section 6(1)(e) : Any other facts which are relevant to the circumstances of her death

[63] On the evidence there were no other facts which are relevant to the circumstances of her death. The first and fourth of the family's concerns are best dealt with under this fifth criterion. The first proceeds on the premise that Mrs Rosenshine was terminally ill. That can only relate to the condition of her heart and as the family concede in their submissions this only became known "with the benefit of hindsight" namely that its true nature only emerged in the course of the post mortem conducted on her. It was not something known to the various members of staff of the Victoria Infirmary who played a role in her care at the time when she was admitted or subsequently, and there was no suggestion in the course of evidence that it ought to have been known by them either by way of perusal of her medical records or by diagnosis when she was under the care of the Infirmary. The premise of the concern, which might be better construed as a poignant observation, is ill-founded in fact, as was really conceded by the family, there is no evidence to support it, and therefore I am in no position to make a determination on it.

 

[64] The fourth raises the issue of whether the RCA ought to have been made available to the family in advance of the Inquiry. There is no evidence to support any such obligation. Mrs McQueen prepared the RCA in the course of her duties as a clinical risk manager. In its Introduction she observed of it that it focused on the clinical aspects of the significant clinical incident that culminated in the death of Mrs Rosenshine, and that it provided commentary on that incident using Root Cause Analysis tools and techniques to examine the procedures and processes around her care (page 189). It concluded with her 7 Recommendations (page 191). All of them relate to how she concluded members of staff ought to act. In her evidence she said that her approach was investigative and once she had completed the RCA she submitted it to management who in light of it then prepared an Action Plan. From this I take that it the RCA was aimed at procedures and processes that are internal to the running of the Infirmary. It had no wider ambit and there was nothing in it that required it to be exhibited to or released to anyone other than those involved in the structural management of the Infirmary. Beyond that she was not asked in examination in chief if she was under any obligation to release to the family a copy of the RCA at any point in time prior to the start of the Inquiry, and she was not cross examined at all. There is therefore no factual basis before the Inquiry for any obligation of the kind suggested by the family. For all these reasons I am unable to make any determination on this concern.