Scottish Sheriff Court Decisions

2011 FAI 12

SHERIFFDOM OF TAYSIDE CENTRAL AND FIFE

AT DUNDEE

Case No:DN0900745

DETERMINATION

By

THOMAS GEORGE HUGHES, Sheriff

In

Inquiry into the circumstances of the Death of

ALEXANDER OGG WYLIE

In terms of Section 6 of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976

DUNDEE: 2011.

The Sheriff having resumed consideration of the Inquiry, Determines as follows:-

1.                 In terms of Section 6(1) (a) of the Act that Alexander Ogg Wylie died at Ninewells Hospital, Dundee on 27^th December 2009 at 22.55 hours.

2.                 In terms of Section 6(1)b) of the Act that the cause of death was atherosclerotic coronary artery disease, with minor blunt force injuries, being a contributory factor.

3.                 In terms of Section 6(1) (c) of the said Act I make no findings.

4.                 In terms of Section 6(1) (d) of the said Act I make no findings.

5. In terms of Section 6(1) (e) of the said Act I make no findings.

I have no further recommendations to make.

Sheriff of Tayside, Central and Fife, At Dundee

NOTE:

Introduction

Mr. Alexander Ogg Wylie resided at 34 Belisle Drive, Dundee. He died on the 27^th December 2009. At the time of his death he was 46 years old and had been employed as a taxi driver.

I carried out an Inquiry into the circumstances of his death in terms of Section 6 of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976. This took place on the 21^st, 22^nd and 23^rd February. During the Inquiry the Crown was represented by Mr. Robertson, Procurator Fiscal Depute, Mr. Reid, Solicitor, represented Tayside Police and Miss MacPhail, Solicitor, represented Tayside Health Board. Members of Mr. Wylie's family were present in Court throughout the proceedings.

During the Inquiry I was asked to consider significant circumstances regarding Mr. Wylie's death and I deal with these as follows:-

1. Incident at the Lowdown Public House and Mr. Wylie's subsequent transfer to Tayside Police Headquarters.

2. The incidents involving Mr. Wylie in the "quadrangle" at Tayside Police Headquarters, Bell Street, Dundee and his onward transmission to the Accident and Emergency Department, Ninewells Hospital, Dundee.

3. The procedure carried out at the Accident & Emergency Department at Ninewells Hospital, Dundee,

4.. The results of the Post Mortem Examination.

5. The use of out-of-hours/forensic medical services available to Tayside Police. At the relevant time.

6. Parties submissions.

7. Conclusion.

Incident at the Lowdown Public House.

The first witness to give evidence was witness no. 4 Detective Constable Simon Murray of Tayside Police. Detective Constable Murray made reference to the fact that on Sunday

27^th December 2009 Officers of Tayside Police had been called to an ongoing disturbance at the Lowdown Public House, 5C Seagate, Dundee. As a result of the police involvement two males were arrested for a Breach of the Peace and four others were detained in connection with the incident. One of the detained males was Mr. Alexander Ogg Wylie.

Detective Constable Murray was the Reporting Officer in this case. He had been advised that Mr. Wylie had been conveyed to Police Headquarters, Dundee. However, shortly after his arrival there he became unwell. He had been in an unmarked police vehicle which had been parked within the "quadrangle" area which was an enclosed yard leading into the entrance of the custody reception area of the said police office. The Detective Constable later learned that Mr. Wylie had been conveyed to Ninewells Hospital, Dundee, where he subsequently died.

At about 9.30 p.m., Constable Murray attended the Lowdown Public House. He spoke to various other officers there. Detective Sergeant Lorente had been made aware of the circumstances and subsequently attended at the Accident & Emergency Department at Ninewells Hospital. There it was confirmed that Mr. Wylie had died. Uniformed officers were asked to remain with Mr. Wylie's body for recovery of any forensic evidence available. Mr. Wylie's family was advised of the unfortunate circumstances and in particular Mr. Wylie's wife, Mrs Alison Wylie and Miss Christine Robertson had been present and had been advised of the unfortunate circumstances.

The Detective Constable was referred to production no.8 which provided detailed information regarding the location of the Lowdown Public House and the significance of the surrounding area.

Production no. 7 was referred to and this provided photographic evidence of the internal area of the said public house. In particular the basement area was of significance and the Detective Constable was able to identify the front of the bar area (photograph 3) and the layout of the basement area where the incident allegedly took place.

The Detective Constable was asked to consider production no. 20 which was a plan of the "quadrangle" area of Tayside Police Headquarters, Dundee. This was an area which allowed police custody vehicles access into the custody reception area. There was a ramp leading from the courtyard into the building. Production no. 9 was shown to the Detective Constable and he was able to identify the "quadrangle" area shown therein and identified various vehicles which had been parked within the area at the time when Mr. Wylie took ill.

A DVD (production no. 23) was shown to the court and the Detective Constable identified this as shown the "quadrangle" area and vehicles which had been parked at the time Mr. Wylie took ill. Paraphernalia which had been left lying on the ground following Mr. Wylie's onward transmission to Ninewells Hospital was visible.

Police Constable Jill Dolan (witness no. 6) made reference to the fact that at approximately 9.20 p.m. on 27^th December she received a radio request over the "link" radio for assistance at The Lowdown premises, 5C Seagate, Dundee, as there was a reported large scale disturbance taking place therein. By the time she arrived at the locus, Constables McKendrick and Johnston were in attendance. The Constable advised that the "link" radio was available to door staff at licensed premises within the Dundee City Centre area. This allowed them to quickly convey information to Police Headquarters regarding potential trouble and to obtain assistance if required.

The three officers attended the premises and went downstairs to the basement area where the incident was allegedly taken place.

Constable Dolan was referred to the photographs in productions no. 7 and was able to identify the area where fights were taking place. In particular she referred to photograph no. 8 in this production which disclosed a seated area. She indicated that different fights were taking place there when she entered. She noticed a female bleeding from a facial wound. Constable Johnston was able to apprehend two males. They had been fighting with each other. One was on top of the other, punching him. The person who was at the bottom was in fact Mr. Wylie. Constable Johnston was able to separate both men and he handcuffed the man who had been on the top. Constable Dolan handcuffed Mr. Wylie. Mr. Wylie was cuffed to the front and was asked to remain in the seated area. He was then brought to his feet. At that time he was verbally aggressive towards the other man. He was told he was being detained and as far as Constable Dolan was concerned he was in legal custody at that time. He was cautioned. He did not say anything. His wife was present at the time. She indicated that she wanted Mr.Wylie's wallet as she required to pay for a taxi to get her home. Mr. Wylie gave permission for her to have the wallet and it was given to her.

At that time Constable Dale Evans attended. Constable Evans was asked to convey Mr. Wylie to Police Headquarters and he agreed to do so. Constable Dolan later learned that Mr. Wylie had suffered cardiac arrest and had died. Constable McKendrick received information that the locus was to be secured for subsequent forensic examination.

The constable confirmed that when Mr. Wylie was with her he was coherent. He had been under the influence of alcohol but there was no indication that he was unwell.

Constable Dale Evans (witness no. 8) gave evidence to the effect that at approximately 9.10 p.m. he received a report regarding a disturbance taking place at the locus. He attended in a marked police vehicle. He entered the premises and noticed that several persons were still engaged in a disturbance. These individuals had been taken into custody and in particular Mr. Wylie had been apprehended. He was cuffed to the front. Constable Dolan asked him if he would convey Mr. Wylie to police headquarters and he agreed to do so.

The constable noticed that Mr. Wylie had superficial grazes to his forehead and cheeks. He did not complain of his injuries. At that time he did not complain he was unwell. Mr. Wylie made reference to the fact that he was having difficulty walking. He had previously had an operation on his legs and he was limping. Mr. Wylie said it was an old injury. During that time Mr. Wylie's wife was also present.

The constable confirmed that Mr. Wylie was compliant with the police officers. Initially he was hesitant but fully co-operated with the officers. He told Constable Evans that he was a taxi driver.

Constable Evans escorted Mr. Wylie to the front of the licensed premises and had intended to place him in the marked police vehicle that Constable Evans had arrived in. Unfortunately at that time another prisoner had been placed in the vehicle. Constable Evans therefore had to wait for another vehicle to become available. Whilst they were standing waiting Mr. Wylie referred to the fact that the handcuffs were causing him discomfort and in particular the left side was too tight for him. Constable Evans indicated that he loosed the cuff to a more comfortable position for Mr. Wylie and thereafter locked it again.

Whilst he was standing at the front door of the premises Mr. Wylie started to interact with another male and remarks were exchanged between them. Constable Evans escorted Mr. Wylie away from that and took him into a doorway nearby next to Blacks shop premises. Whilst there Mr. Wylie was compliant again and there was no further issues with him. In particular he did not complain of feeling unwell. Constables North and McKay arrived at the scene in an unmarked police vehicle (a silver ford car) Mr. Wylie was handed over to them and they thereafter conveyed Mr. Wylie to police headquarters.

The court was shown production no. 24 a DVD which showed CCT images from the locus at the relevant time. Constable Evans gave a commentary on what happened at the relevant time. The images contained within the production were entirely consistent with the evidence that Constable Evans had given in his previous narration of the incident.

The unmarked police vehicle was seen leaving the locus at 21.26.23 hours. Mr. Wylie was in the vehicle at that time being conveyed to police headquarters.

Incident at Police Headquarters

Constable Steven McKay (witness no. 10) gave evidence regarding his initial attendance at the locus with Constable David North. They had also received information regarding the disturbance at the Lowdown Public House and attended as quickly as they could. They were in an unmarked police vehicle. It was a silver Ford Focus motor car registration no. SP07 JNK. This is an unmarked vehicle which is utilised by the licensing department during the commission of their own business. Out of office hours the vehicle is available to uniformed officers, if required. During the late shift of Sunday 27^th December the vehicle was utilised by the Community Engagement Team. Constable McKay was part of that team. The officers attended the locus at about 21.20 hours. By that stage matters had calmed down. The officers spoke with Constable Evans and he requested that they convey Mr. Wylie to police headquarters. Constable Evans had Mr. Wylie at the doorway of Blacks. The officers were informed that Mr. Wylie had been detained in terms of Section 14 of the Criminal Procedure (Scotland) Act 1995. Mr. Wylie had been cuffed to the front and showed no signs of obvious injuries.

The officers arranged to place Mr. Wylie in the rear of their vehicle. Constable McKay was driving and Constable North sat in the back beside Mr. Wylie. The vehicle was then driven to police headquarters at Bell Street, Dundee. During the journey Mr. Wylie did not complain of feeing unwell. He was concerned and asked the officers what was likely to happen to him. He narrated the fact that he had been involved in a fight but that was purely to try to help his son, who had been involved in an earlier incident. Mr. Wylie was coherent. He was upset.

Constable McKay gained access to the courtyard known as the ("quadrangle") which is used by police vehicles to convey prisoners into the custody reception area of the police headquarters. Constable McKay stopped in the courtyard. Constable North left the vehicle and went into the building. Other prisoners had been arriving at the same time and the officers wanted to ensure that there were no rival factions meeting in the custody reception area. It was decided that prisoners should be kept apart at that time. Constable McKay had been left alone in the vehicle with Mr. Wylie. During the wait Mr. Wylie engaged in conversation with the constable. They spoke of what was likely to happen to Mr. Wylie. The conversation continued about his occupation as a taxi driver and football matters.

At about 21.42 hours Mr. Wylie indicated that he was feeling sick and requested fresh air. Constable McKay got out of the vehicle and made his way to the rear side door and opened it to give Mr. Wylie some fresh air. He supported him by the shoulder. As he did so Mr. Wylie was not sick and continued with his conversation to the police officer.

Constable North returned from the building and at that point Constable McKay had thought Mr. Wylie had fallen asleep. He heard a snoring noise coming from Mr. Wylie.

Constable North leaned into the police vehicle and tried to awaken Mr. Wylie. He was unsuccessful in doing so. Constable North checked for a pulse and could not find one. Constable McKay thereafter also tried to find a pulse but without success. At that stage the officers realised that Mr. Wylie was not breathing.

Constable Sean Porter arrived at that time in another vehicle. He was alerted to the situation and three police officers arranged for Mr. Wylie to be removed from the police vehicle and placed on the ground at the door where Mr. Wylie had been sitting.

The handcuffs were removed from Mr. Wylie and Constable Porter and other officers at that stage attempted to administer first aid. Urgent medical assistance was requested and an ambulance and a rapid response vehicle attended almost immediately.

The officer was asked to look at production no. 22 which was a DVD showing CCTV images taken at the relevant time. Again the officer's narration of the events coincided exactly with the CCTV images.

The images disclose that the police vehicle arrive in the "quadrangle" at 21.29.15 hours. Constable McKay seemed to leave the police vehicle at 21.41.56 hours to attend to Mr. Wylie. Constable North is shown to return to the vehicle at 21.53 hours. Constable Porter arrives at the scene to assist his colleagues at 21.56 hours. The ambulance attends and Mr. Wylie is placed on a trolley at 22.12.31 hours. At 22.15.10 hours Mr. Wylie is placed into the ambulance for onward transmission to Ninewells Hospital.

Constable David North (witness no. 9) gave similar evidence to that of his colleague Constable McKay. He confirmed that when the police vehicle had been confined to the "quadrangle" he left the vehicle. He went into the custody reception area to advise the custody assistants about Mr. Wylie's arrival. He spoke to officers, providing them with Mr. Wylie's details. He returned to the vehicle and was advised by his colleagues that Mr. Wylie had appeared to be sleeping. He attempted to rouse Mr. Wylie by pinching his ear. That was unsuccessful. He thereafter rubbed his sternum with a view to awakening him. This was standard police procedure. These efforts were unsuccessful and following examination it was noted that Mr. Wylie was not breathing. He referred to Constable Porter's attendance at the scene and the efforts that all three police officers made to remove Mr. Wylie from the vehicle and to provide first aid. Constable North carried out chest compressions. Whilst this was happening other officers called for medical assistance. A fast response vehicle and ambulance attended almost immediately.

Constable Sean Porter (witness no. 11) had driven into the "quadrangle" in a marked police vehicle. His attention was drawn to the unmarked police vehicle where two officers were nearby. He knew that they were in some difficulty and he asked his colleague Constable Watt to remain with the prisoner in his own vehicle. At first Constable Porter believed that his colleagues had been dealing with an aggressive prisoner. However he noted that the male in the police vehicle, Mr. Wylie, was unwell. Constable North had tried to find a pulse and had been unable to do so. All three officers took Mr. Wylie from the vehicle and laid him on the ground to get better access to him. There was no evidence of a pulse or breathing. Constable Porter shone a torch into Mr Wylie's eyes. There was no movement. Constable Watt was instructed to summon an ambulance immediately and she did so. She also ran into the building to see if she could have medical assistance. It had been hoped that a nurse might be inside but they were advised that there were no nurses in police headquarters at that time.

Constable Porter estimated that the ambulance did in fact arrive within 10 minutes. One of the first paramedics to arrive attached a defibrillator and shocked Mr. Wylie. Unfortunately that did not have the desire effect. It was attempted twice. In the meantime police officers continued with CPR.

Steven Keir (case witness no. 15) is an ambulance paramedic. On the night of the 27^th December he was on duty in the Fast Response Unit. He received intimation that a male had collapsed within police headquarters and he was instructed to attend. The purpose of the Fast Response unit was to attempt to provide a quick response by car to attend incidents, commence medical procedures and on the arrival of an ambulance to provide backup to the paramedics. On the 27^th December Mr. Keir was the first paramedic to attend the scene. He gained entry into the "quadrangle" and found Mr. Wylie lying on the ground. Police Officers were attempting chest compression. Mr. Keir checked the patient for a pulse and for breathing with a negative response on both accounts. He asked the officers to continue CPR and he attached a defibrillator to Mr. Wylie. He started the defibrillator and he noticed that the rhythm of Mr. Wylie's heart was chaotic. At around 22.06 he shocked the patient. He then observed that the heart rhythm on the screen was pulse less electrical activity. The patient was in cardiac arrest. The shock had been administered in an attempt to regulate the heartbeat but that had not been effective. Mr. Keir requested that police officers continue the CPR and continue to monitor the patient. He could not remember how many times a shock was administered.

The ambulance arrived. His colleagues took over the emergency treatment. CPR continued and Mr. Wylie was placed in the rear of the ambulance for onward transmission to the Accident & Emergency Department of Ninewells Hospital. Mr. Keir could not remember if any form of medication had been administered to Mr. Wylie. He accompanied Mr. Wylie by ambulance and assisted CPR continually throughout the journey until the ambulance arrived at the Accident & Emergency Department of Ninewells Hospital. At that point Mr. Wylie was handed over to the care of the staff within the hospital.

The witness Matthew Thomas Bell (witness no.16) gave similar evidence to that of Mr. Keir. He had been driving an ambulance on the evening in question along with his colleague Liane Roy and they were summoned to assist Mr. Wylie. They attended immediately at police headquarters as soon as they had received intimation of the call and it took them approximately five minutes to arrive. Mr. Bell referred to the efforts made to try to resuscitate Mr. Wylie. On the journey from the police office to Ninewells Hospital, he drove the ambulance. They had the benefit of a police escort. He estimated that it took approximately 4 minutes to journey between the police office and the hospital. Throughout the entire journey CPR continued. Mr. Bell alerted the hospital that he was on route to the Accident & Emergency Department. He provided them with a basic history of what had happened and asked for assistance to be made available to them immediately on their arrival at the Accident & Emergency

Department. He confirmed that throughout the journey Mr. Wylie had failed to recover at any time.

Procedure at Ninewells Hospital

Dr. Fraser William John Denny (witness no. 17) gave evidence regarding Mr. Wylie's admission to hospital. Dr. Denny is a Speciality Registrar in Emergency Medicine and by December 2009 he had some 18 months' experience in that position. In the evening when Mr. Wylie was admitted the Consultant in charge of the department was Dr. William Morrison.

On 27^th December 2009 at approximately 10.30 p.m., Dr. Denny was working in the Accident & Emergency Department. Staff had been advised in advance that Mr. Wylie was due to be admitted to the department. Preliminary information regarding his condition was conveyed to him. The purpose of this was to ensure that relevant staff were available and the necessary equipment made ready.

Dr. Denny was referred to production no. 29 and to Mr. Wylie's medical records.

It was confirmed that according to Triage notes, Mr. Wylie arrived within the department at 22.34 hours. According to the nursing notes Mr. Wylie had collapsed at the police station and suffered a cardiac arrest. CPR was ongoing. Under the heading of "intervention" it is noted that observations were unrecordable at arrival within the department. There was no pulse. The indications were consistent with cardiac arrest. Dr. Denny was responsible for passing a tube into Mr. Wylie's lungs in an attempt to assist him in breathing. Mr. Wylie was heard to make occasional gasps which he referred to as "agonal respirations". The Dr. referred to this as a respiratory effort which occurs at the end of life. Dr. Denny outlined the further procedure which was carried out on Mr. Wylie. He referred to the protocol which was used for patients such as Mr. Wylie. On two occasions the defibrillator was used to administer two shocks in an attempt to instigate a heart beat. Initially there was a brief success and electrical rhythm started but with a very faint pulse. However, that did not last long unfortunately. Adrenalin was administered with further CPR. Every step of normal procedure was carried out, but Mr. Wylie was found to be asystolic, showing no heartbeat and in cardiac arrest.

Dr. Denny was joined by Dr. Morrison during that time. Dr. Morrison was not actively involved in the procedures carried out on Mr. Wylie but oversaw what was taken place and was available for consultation if required. All agreed that any further efforts to resuscitate Mr. Wylie would have been futile and he was therefore pronounced life extinct at 22.55 hours on the 27^th December 2009.

Mr. Wylie's family were present in the hospital during and at the relevant time and the unfortunate information was passed on to them.

Dr. Denny had in fact noted that Mr. Wylie had various injuries on his body namely bumps and bruises but there was nothing in particular that would have caused the cardiac arrest.

Dr. William George Morrison was the Consultant in charge of the department at the time when Mr. Wylie was admitted to the Accident & Emergency Department at Ninewells Hospital on 27^th December 2009 at 22.34. He was brought to the hospital by ambulance and was treated by a team led by Dr. Denny who was a senior doctor. Initially, Dr. Morrison was not able to see Mr. Wylie as he had been dealing with another patient, but attended to assist Dr. Denny as soon as he possible could. Dr. Morrison indicated that he was there in a supervisory capacity only and available for consultation if required. Dr. Morrison had full confidence in Dr. Denny and allowed him to continue with the procedures carried on Mr. Wylie. Dr. Morrison confirmed that he personally would not have been able to do anything different for their patient. He indicated that there was a clear protocol for the treatment of patients who had gone into cardiac arrest and Dr. Denny followed that protocol. Once all treatment had been carried out a brief discussion took place and it was agreed that any further intervention would have been futile. Notes indicate that Mr. Wylie was pronounced life extinct at 22.55 hours.

Dr. Morrison indicated that there was a further protocol used on patients who had suffered cardiac arrests outwith hospital premises. If paramedics attended they would initially check for a pulse, start the patient breathing if possible and drugs could be administered by the paramedics. However, current available statistics indicate that individuals who suffer cardiac arrest outwith hospital have poor prospects of a successful discharge from hospital in due course. The figures currently available indicate a figure of less than a 10 per cent success rate. Taking all the evidence into account Dr. Morrison was of the view that it was not a surprise that the unfortunate outcome for Mr. Wylie was not positive.

Results of Post Mortem Examination

Dr. David William Sadler gave evidence to the effect that he carried out an autopsy on Mr. Wylie on the 29^th December 2009. He was assisted by his colleague Dr. Helen Brownlow. He was referred to production no. 3 which was a copy of his report. He noted minor scattered bruises and abrasions to the forehead, face and lips together with abrasions to the knuckles of the left hand and bruises and abrasions to both forearms and elbows. There were minor scraping abrasions to the inside of the right kneecap and bruising to the right shin. These injuries would have been in keeping with involvement in a fight shortly prior to death. There had been no skull fracture or underlying brain injury. His sternum was fractured in keeping with medical attempts at resuscitation. The autopsy revealed severe hardening and narrowing of one of the three main blood vessels supplying blood to the heart (atherosclerotic coronary artery disease). That vessel seemed to be occluded by a flap-like fragment of ruptured plaque, which was a recognised acute complication of chronic atherosclerotic coronary artery disease. In addition the right coronary ostium which represents the origin of the right coronary artery was also moderately narrowed by atherosclerosis. The lungs were flooded by fluid which is a common feature of terminal heart failure. The autopsy revealed no internal injuries. Death was attributed primarily to atherosclerotic coronary artery disease. It was well recognised that a rise in pulse rate and blood pressure associated with emotional upset and physical exertion or injury may precipitate a disturbance in the electrical rhythm of the heart or atherosclerotic plaque rupture. Therefore if there had been any involvement in an altercation and minor blunt injury then these would be viewed as significant contributory factors to Mr. Wylie's death. The injuries in themselves would not have been fatal but the sequence of events strongly suggested that the stress associated with the altercation precipitated death from pre existing natural disease.

Use of forensic medical services

Sally Patrick, witness no. 22, gave evidence regarding the use of the out-of-hours/forensic medical services available at the time of Mr. Wylie's death. She is of some 37 years experience and is the project leader of the forensic medical service in NHS Tayside. She made reference to the pilot project for Tayside which was set up on 12^th January 2009. This is a 3 year pilot project. This made provision for medical intervention to be available on site within custody suites in Tayside, 24 hours a day and 7 days a week. A nurse was on duty to cover the Tayside area between the hours of 7.30a.m. and 6.30p.m. each working day. From 6.30 p.m. until 7.30 a.m., two nurses were available. Two nurses were also available each weekend and public holidays. The nurses take referrals from the Custody Sergeants in the three areas they serve, namely Dundee, Perth and Arbroath. Persons in custody can seek help from the nurses or police officers might want to refer detainees to the nurses.

Nurses mainly treat persons suffering from opiate withdrawal. They could provide some basic medication after 6 hours had elapsed from time of arrest.

If a detainee collapsed or was seriously unwell then a custody sergeant would arrange for that person to be conveyed to the Accident & Emergency Department of the local hospital. Nurses would be advised of the Custody Sergeant's decision to do so.

The Custody Care Assistants located in each cell area have basic first aid skills. They are trained by Tayside Police. Defibrillators have been provided and staff trained in their use.

In December 2009 at the time of Mr. Wylie's death Custody Care Nurses were working in Tayside. At the time when Mr. Wylie took ill two nurses were on duty. One had been sent to Perth Police office whilst the other had been instructed to attend Arbroath Police office. Neither of these nurses was involved in treating Mr. Wylie.

Dr. Morrison was asked to consider whether or not the use of these nurses would have assisted Mr. Wylie in any way. In December 2009 this was an innovative project and apart from limited resources being available in Lothian, Tayside was the area which had been designated to use this pilot project.

Mr. Wylie became unwell at the Police Headquarters. Dr. Morrison did not believe that anything else could have been done for Mr. Wylie even if the nurses had been in attendance. Police Officers were available to administer CPR at a very early stage when Mr. Wylie became unwell. The correct management was carried out from the time when Mr. Wylie became unwell until the time he was pronounced dead. Staff from the forensic medical service would not have been able to do anything that would have changed the outcome for Mr. Wylie.

Submissions

Mr. Robertson for the Crown asked me to return a formal verdict in this case. He asked me to make a finding in respect of Sections 6(1)(a) and (1)(b) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 thereby setting out where and when the death took place and the cause or causes of such death. Mr. Robertson submitted that no reasonable precautions could have been taken which would have avoided Mr. Wylie's death. There were no defects in any system of working which contributed to the death. There were no other facts which were relevant to the circumstances of the death. He therefore indicated that I should make no findings in respect of Sections 6(1) (c), (d) and (e) of the said Act.

Mr. Reid made similar submissions to Mr. Robertson. He referred to the evidence given by Dr. Sadler setting out the circumstances of Mr. Wylie's unfortunate death and asked me to accept that Tayside Police Officers did everything they possibly could to assist Mr. Wylie.

Miss MacPhail referred me to the reports from Dr. Denny, Dr. Morrison and Dr. Sadler and asked me to hold that the medical care provided to Mr. Wylie was entirely appropriate to the circumstances of his condition. Unfortunately nothing further could be done to save Mr. Wylie. She referred me to the times quoted when Mr. Wylie took ill and submitted that there had been a very quick response from the emergency services. Mr. Wylie was admitted to hospital at the earliest opportunity available and notwithstanding all of the efforts which had been made to try to revive him, nothing further could be done to save him.

Dr. Morrison had made it quite clear that in all of these circumstances surrounding Mr. Wylie's admission to hospital that no other procedure could have been carried out which would have saved Mr. Wylie and the fact that nurses had not been available at Tayside Police Headquarters at the relevant time would not have changed the outcome for Mr. Wylie in any way.

CONCLUSION

The circumstances of Mr. Wylie's death were extremely unfortunate. On Sunday 27^th December 2009 police officers were called to the Lowdown Public House, Dundee, in response to an ongoing disturbance which was taken place there. Mr. Wylie was apprehended by police officers as a result of that disturbance. From the evidence available to me the officers' conduct throughout the time when Mr. Wylie was at the locus was entirely appropriate and he seemed to be treated with courtesy and consideration by the officers concerned. Police Officers involved gave direct evidence about this matter and I was also able to see the evidence from the CCTV coverage that confirmed the officers account of what happened.

Mr. Wylie was transferred from the locus to the "quadrangle" at Tayside Police Headquarters, Dundee. During that time he was in the custody of Constables North and McKay. The officers had no idea that Mr. Wylie was unwell during the journey from the locus to the police office and were able to converse with him during the journey to the police office. Constable North entered the building whilst Constable McKay remained with Mr. Wylie. Constable McKay was able to converse with him and at a time when Mr. Wylie indicated that he was feeling sick Constable McKay tried to assist him. The Officer opened the door of the vehicle to allow Mr. Wylie some fresh air and was able to support him in case he was sick. After a very brief period Constable North emerged from the building and at that stage it was thought that Mr. Wylie was sleeping. The officers almost immediately realised that Mr. Wylie had collapsed and those officers together with other colleagues did everything they could to try and assist Mr. Wylie. The ambulance services were alerted almost immediately. Paramedics arrived on the scene rapidly. They tried to assist Mr. Wylie as much as he could at the scene and thereafter transferred him to the Accident & Emergency Department of Ninewells Hospital as quickly as they could.

I accepted the evidence of Drs Denny and Morrison outlining the various procedures which were carried out upon Mr. Wylie with a view to trying to save his life. Both doctors were very clearly of the view that absolutely nothing further could have been done to save Mr. Wylie.

Having heard all of the evidence in this case I took the view that all police officers involved, the paramedics and doctors who tried to save Mr. Wylie did everything that could have been asked of them in their professional capacity.

I accepted the evidence of Dr. Sadler that unfortunately Mr. Wylie had a pre-existing medical condition of severe hardening and narrowing on one of the three main blood vessels supplying blood to his heart. Death was attributable primarily to that cause. I also accept Dr. Sadler's opinion that it was well recognised that a rise in pulse rate and blood pressure associated with the emotional upset, physical exertion or injury can precipitate a disturbance in the electrical rhythm of the heart. In that way involvement in an altercation and minor blunt force injuries are viewed as significant contributory factors. Although the injuries in themselves would not have been fatal, the sequence of events strongly suggested that the stress associated with the altercation precipitated Mr. Wylie's death from his pre-existing natural disease.

I accepted the evidence of Dr. Morrison that the absence of nurses from the cell area at police headquarters at the time when Mr. Wylie took ill would have had no effect on the outcome for Mr. Wylie.

I therefore hold that there were no reasonable precautions which could have been taken which might have avoided Mr. Wylie's death. There were no defects whatsoever in any system of working which contributed to his death and there are no other facts which would be relevant to the circumstances of Mr. Wylie's death.

I am very grateful to all the witnesses who gave evidence in this case and to Mr. Robertson, Mr. Reid and Miss MacPhail for the assistance they provided to the court during the course of the inquiry and for their helpful submissions.