Scottish Sheriff Court Decisions

SHERIFFDOM OF SOUTH STRATHCLYDE, DUMFRIES AND GALLOWAY AT KIRKCUDBRIGHT

 

2010FAI27

 

 

DETERMINATION

 

by

 

SHERIFF DONALD CORKE, ADVOCATE

 

in an Inquiry into the circumstances of the death of

 

VICTORIA CELIA PICKUP

 

under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976

 

APPEARANCES:

For the Crown: Ms Rhodes, Procurator Fiscal Depute

For Dr Soeren Schoenhoff, Dr Mhari Williamson and Dr Iain Carmichael: Ms Donald, Solicitor

 

Kirkcudbright, 24 May 2010

 

The Sheriff, having considered all the evidence adduced and the submissions made thereon, determines in terms of section 6 of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976 ("the Act"):

 

1. That in terms of s.6(1)(a) of the Act, Victoria Celia Pickup, who was born on 7 October 1981, died on 15 February 2007 at 18h45 in the resuscitation room at Dumfries and Galloway Royal Infirmary.

 

2. That in terms of s.6(1)(b) of the Act, the cause of death was:

	(a) Streptococcal septicaemia;
	(b) Fulminant bronchopneumonia.

 

3. That in terms of s.6(1)(c) of the Act, there were no reasonable precautions which could have been taken whereby the death might have been avoided.

 

4. That in terms of s.6(1)(d) of the Act, there were no defects in the system of working which contributed to the death.

 

5. That in terms of s.6(1)(e) of the Act, any other facts which are relevant to the circumstances of the death are set out in the following Note.

 

 

 

Sheriff

 

NOTE:

 

Introduction.

 

[1]     Victoria Pickup was a happy and healthy young woman until she was taken ill in the days before her death. I shall refer to her as "Victoria" to differentiate her from her mother. She was treated in her final illness by local GPs Dr Soeren Schoenhoff, Dr Mhari Williamson and Dr Iain Carmichael. Notwithstanding their treatment, and to the great distress of all concerned, Victoria died in the early evening of 15 February 2007 in the resuscitation room at Dumfries and Galloway Royal Infirmary. The conditions from which she died - streptococcal septicaemia and fulminant bronchopneumonia - are rare in an otherwise healthy young person. It appeared to the Lord Advocate to be expedient in the public interest that an Inquiry under the appropriate Act should be held into the circumstances of her death. This Inquiry is the result.

 

Witnesses and productions

 

[2]     Evidence was heard over three days, with submissions on a separate day.

 

[3]     There was a list of productions with 11 items (pro no 1 - pro no 11).

 

[4]     The following is a list of those witnesses who gave oral evidence to the Inquiry, together with details, where appropriate, of their status at the relevant time.

 

1.      Mrs Celia Pickup (Victoria's mother);

2.      Richard Pickup (Victoria's father);

3.      Allison Patterson (friend of family and Victoria's former nanny);

4.      Dr Soeren Schoenhoff, GP registrar (trainee) at the Garden Hill Primary Care Centre, Castle Douglas Medical Group ("Garden Hill");

5.      Dr Mhari Williamson, GP, partner at Garden Hill;

6.      Dr Iain Carmichael, GP, partner at Garden Hill;

7.      Dr John Amuesi, Consultant Pathologist, Dumfries and Galloway Royal Infirmary and author of the autopsy report (pro no 1);

8.      Professor Andrew Peacock, Consultant Respiratory Physician at West Glasgow Hospitals University NHS Trust and author of medical report on the death (pro no 5);

9.      Dr Norman Wallace, author of independent expert GP report (pro no 4);

10. Dr Angus Cameron, Medical Director, NHS Dumfries.

 

[5]     The evidence of Dr John Burton, A&E Consultant, was received by way of affidavit.

 

Duties and powers of the Sheriff.

 

[6]     Victoria's relatives were not represented, though her parents gave evidence. That being so, it may be helpful, particularly for their sake, to set out the duties and powers of the Sheriff in respect of such a determination.

 

[7]     These are contained within section 6 of the Act. This section provides as follows:-

 

"6. (1) At the conclusion of the evidence and any submissions thereon, or as soon as possible thereafter, the sheriff shall make a determination setting out the following circumstances of the death so far as they have been established to his satisfaction -

 

(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."

 

[8]     There are certain preliminary matters worth mentioning and these are that:-

 

(a)             The findings must be based on the evidence led at the Inquiry (Smith v LA 1994 SLT 379).

 

(b)              An Inquiry of this nature is not determining any question of civil fault or liability or apportioning blame (Black v Scott Lithgow Ltd 1990 SLT 612).

 

(c)               For a finding that there was a reasonable precaution whereby the death might have been avoided, there requires to have been evidence led as to how the physician concerned ought to have acted.

 

(d)              Any determination cannot be founded upon in any subsequent proceedings (section 6(3) of the Act).

 

(e)              In terms of section 4(7) of the Act the rules of evidence shall be as nearly as possible those applicable in an ordinary civil cause brought before the sheriff.

 

(f)                The standard of proof is the balance of probabilities and facts and circumstances can be established without the necessity of corroboration.

 

Submissions

 

[9]     At the end of the Inquiry, both Ms Rhodes and Ms Donald helpfully provided written submissions, upon which they relied.

 

[10]They were agreed on the appropriate conclusions on s.6(1)(a)-s.6(1)(d) of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976 ("the Act") and as those accord with my own view of the evidence, these are reflected in the determination above.

 

Submissions for the Crown

 

[11] After brief reference to her role as Procurator Fiscal Depute, s.6 of the Act and general principle, Ms Rhodes made submissions on s.6 as above. On the remaining matter, s.6(1)(e), she noted the fact that the cause of death was rare in an otherwise healthy young person, as spoken to by various witnesses. She noted the symptoms of Streptococcus Group A and ended as follows:

 

Although the evidence indicated that an illness and death such as that suffered by Victoria Pickup is very rare it is my submission that medical practitioners should be alert to such a possibility.

 

Submissions for Drs Schoenhoff, Williamson and Carmichael.

 

[12] Ms Donald provided an introduction and overview of the statutory framework and the law, before making submissions in terms of s.6 as previously noted. As far as s.6(1)(e) was concerned, it was her submission that any other factual circumstances relevant to the circumstances of the death of Victoria might be recorded under this heading. It was her submission that there were no other relevant facts relating to her clients to be dealt with here, and any comments might appropriately be contained within a note to be read alongside the formal determination. The determination should be issued in purely formal terms.

 

[13] She went on to deal extensively with the evidence.

 

Credibility and reliability of witnesses

 

[14] All three of the doctors who treated Victoria - Dr Schoenhoff, Dr Williamson and Dr Carmichael - appeared to me to be trustworthy individuals who were accurately recollecting events to the best of their professional ability. Dr Schoenhoff, although a trainee, is a conscientious individual, credibly considered by his trainer (Dr Williamson) as a good doctor. He did not hide the fact that part of his computer note (pro no 2) was written in retrospect due to a computer failure, and did not state to be true that which he could not actively remember. Dr Williamson and Dr Carmichael are both highly experienced, qualifying in 1978 and 1967 respectively (Dr Carmichael having since retired). All three were deeply affected by this sad death. I regard their evidence as credible and reliable, and insofar as other evidence contradicted their account of events, I prefer their account. The summary that follows is also supported by the expert evidence.

 

[15] The concerns of the family relate to the examination and treatment Victoria received, in particular from Dr Schoenhoff and Dr Williamson. This is based on the recollections of her parents and Allison Patterson, which is not surprising given the great stress of the situation and the difficulty in accurately recalling details that could not have seemed significant at the time. Much of what they had to say is uncontroversial but I shall deal with particular difficulties in due course.

 

[16] There was no reason to doubt the credibility and reliability of the other witnesses, or their expert opinions where offered. The particular expert in the field in this Inquiry was Professor Peacock, whose report I mention below.

 

[17] One particular point to note, however, is that Dr Wallace was proceeding on the basis that Dr Williamson did not adequately question the original diagnosis of gastroenteritis (pro no 4 para 4.15). In fact, I accept her evidence that she did not know of the original diagnosis.

 

[18] Even so, none of the expert witnesses pointed to anything that the doctors should reasonably have done which might have saved Victoria.

 

Summary of events

 

[19] The Pickup family returned from holiday on Sunday, 11^th February 2007. Sunday and Monday were unremarkable. On Tuesday 13^th February, Victoria became unwell, with vomiting. She was still unwell on Wednesday 14^th.

 

First appointment: GP surgery: 15h30, Wednesday 14^th February.

 

[20]                               Dr Schoenhoff saw Victoria in the afternoon of the day before she died. He took a history. She had returned from holiday two days previously. She had been vomiting the night before the appointment, had some diarrhoea, and had been sick at the surgery. The bowl was brought in for inspection.

 

[21] He examined her, particularly noticing a rash on her back. She had a fine rash to the back of her neck and top of the trunk and fine spots on the hairline. He did not notice anything about her face. He was not too concerned about the rash because it was blanching. He thought it was a sign of the vomiting and diarrhoea because a rash accompanies nearly any form of infection.

 

[22]He had asked her to lean back and say "99" (a test using transmitted voice sounds to detect underlying consolidation or fluid on the lung). He tapped on her chest with his fingers for signs of consolidation or inflammation and found nothing suspicious. The doctor did not have a clear mental picture of using a stethoscope, but I accept that he did so because the evidence was that he would have done and had no reason not to. Moreover, his note, albeit in retrospect, could not have been written without the use of a stethoscope. I consider Mrs Pickup to be mistaken in her strongly stated evidence that he did not use a stethoscope. I also prefer his evidence, and that of Dr Williamson, to that of Mr Pickup who reported Victoria as having said that she had not been examined with a stethoscope. The inference must be faced that he was mistaken or, in her distress, Victoria was.

 

[23]He did not notice signs of shortness of breath, or a blue tinge round the lips. Had he been concerned about pulmonary embolism or pneumonia he would have sent her to hospital.

 

[24]The doctor was told of pain in her back especially in the lower back below the rib cage on the right-hand side. That made him think of the possibility of a kidney infection or urinary tract infection. She provided a urine sample and no abnormalities were detected. This sample was not for the purpose of checking pregnancy, as Mrs Pickup opined, which would require it to be sent away. He prescribed co-codamal for the pain in her back which he thought was muscular, being tense when pressed.

 

[25]The main symptoms were vomiting and diarrhoea. He had seen tummy pain and diarrhoea in other patients. The diagnosis of "viral enteritis" in the notes came from the vomiting, diarrhoea and rash and the endemic gastroenteritis which I accept was in Castle Douglas at that time. Mrs Pickup insisted at first that "other GPs" had said it was not going around. Under questioning by Ms Donald, she acknowledged that the impression that gastroenteritis was not going around was based on speaking to one unnamed GP.

 

[26]Dr Schoenhoff did not take her temperature because he felt it was not markedly raised. Temperatures would fluctuate even in acute illness. Her pulse rate was up but not worryingly so.

 

[27] He suggested Olbas oil to loosen anything causing a "funny smell" in her breath.

 

[28]He had not noticed any of the usual symptoms of bronchopneumonia, namely cough, fever, or cyanosis (blueness to lips or fingertips). If he had, he would have administered oxygen and arranged admission to the Royal infirmary in Dumfries.

 

[29]He told her to come back if her condition did not settle.

 

Home visit: Dr Williamson: about 11h30 Thursday, 15^th February

 

[30]                               Dr Williamson was on the way to another house call when she was called to the telephone to speak to Mrs Pickup, who was worried about Victoria becoming dehydrated as she had been sick all night. There was nothing said to indicate that Victoria had seen Dr Schoenhoff the day before. If it had been mentioned, she would have looked at Dr Schoenhoff's note.

 

[31] When she arrived at the house, she had medicines in her hand and a black bag over her shoulder. She specifically took Stemetil to suppress vomiting. There is no evidence that Stemetil was inappropriate.

 

[32]I am satisfied that Allison Patterson, who took her to see Victoria in the absence of Mrs Pickup at a dental appointment, was mistaken in stating that Dr Williamson was not carrying a handbag or anything else at all. The bag, which Dr Williamson had in court, was quite unobtrusive and the fact acknowledged by Allison Patterson that an injection was given obviously indicates that the doctor was carrying something. Dr Williamson had a larger medical kit in the car.

 

[33]Dr Williamson saw Victoria, who was sitting up and answering questions. She checked her pulse, asked her to stick out her tongue, and picked up the skin on the back of her hand to test for dehydration. There was a history of diarrhoea. She noticed a rash on the hip and abdomen, and noticed she had red cheeks and a rash on the face, which she thought went along with a viral infection. She gave her an injection in her left hip. Although Victoria, who had been breathing normally, started taking deep breaths and said that her breathing felt "funny" and "not right" just that morning, she denied her chest being tight, or being wheezy or it hurting her to breathe. She seemed anxious. Dr Williamson listened back and front with a stethoscope and nothing gave cause for concern. She thought it was a viral infection and the priority was to stop the vomiting. Victoria did not mention lower back pain and did not seem uncomfortable. She would have noticed if her lips had been blue or purple, and she had asked to stick her tongue out. She noticed her tongue was moist and pink. Had Victoria had blue lips, then Dr Williamson would have dialled 999.

 

[34]The evidence from Professor Peacock showed that if, as I accept, Victoria was not displaying cyanosis on examination by Dr Williamson, then she could not have been exhibiting those signs the previous day when examined by Dr Schoenhoff. It does not reverse without treatment.

 

Telephone calls 15h30 Thursday, 15^th February and subsequently, and attendance.

 

[35]Dr Carmichael took a telephone call from Mrs Pickup at about 15h30 in the afternoon of the same day Victoria had been seen by Dr Williamson. He had access to her notes. Mrs Pickup was asking about hyperventilation, and Dr Carmichael suggested rebreathing using a paper bag. He offered to go out but that was not taken up at that time.

 

[36]Dr Carmichael was called out to Castle Douglas Hospital, where he was telephoned by the receptionist to be told that Mrs Pickup had telephoned about a drastic worsening in Victoria's condition. Specifically, Victoria's lips had gone purple. An ambulance was called and Dr Carmichael went as well.

 

[37] He arrived at Victoria's home at about 17h20. She was in a chair at the window for air, and was breathing very fast, with effort. Her lips were dark blue. He thoroughly examined her chest with a stethoscope, by percussion and checking expansion and found no unusual sounds on examination, and chest expansion was normal. He suspected pulmonary embolism, but did not suspect bronchopneumonia and Streptococcus A. The ambulance technicians gave her oxygen and she was taken by ambulance to hospital. Notwithstanding all efforts at resuscitation, she unfortunately died at 18h45 in the resuscitation room at Dumfries and Galloway Royal Infirmary.

 

[38]This was not something he had seen before in his professional life.

 

Cause of death

 

[39]It may be of assistance to note the condition from which Victoria died.

 

[40]                               The evidence was that the development of streptococcal septicaemia from a fulminant bronchopneumonia is a very unusual occurrence in general practice, particularly in an otherwise healthy young person.

 

[41] A summary is provided in Professor Peacock's medical report (pro no 5). Pneumonia is an infection of the lung tissue which reduces gas exchange and therefore causes difficulty breathing and low oxygen levels in the blood.

 

[42]A pneumonia picked up in the community by someone with no previous lung disease is known as a primary community acquired pneumonia. Common types are (1) bacterial, usually streptococcal and (2) viral. Common symptoms of pneumonia are breathlessness, cough with or without sputum, general malaise, and chest pain due to inflammation of the pleura (lining of the lung) if there is involvement of the pleura.

 

[43]Vomiting and skin rashes are not typical features of pneumonia.

 

[44]Typical signs of pneumonia are a breathless patient with high fever. There may or may not be signs of hypoxaemia (low levels of oxygen in the blood) causing blueish discolouration of lips and hands. In the chest there are signs of bronchial breathing and may be crackles. There may be signs of pleurisy detectable by stethoscope.

 

[45]It is managed by correction of the oxygen deficit, correction of dehydration and antibiotics. In severe cases the patient will need intubation and ventilation.

 

[46]Septicaemia developed as a consequence of fulminated streptococcal pneumonia and that led to Victoria's death. Septicaemia can lead to a rapid deterioration in condition, even over an hour or two.

 

[47] Victoria's condition, on the facts as found, presented in a very atypical fashion as narrated above.

 

[48]Approximately 100 mls of pus were found in the right pleural cavity at autopsy. The left pleural cavity was normal. It is possible to suffer severe pneumonia yet the auscultatory findings remain normal.