SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH Sheriff John Horsburgh QC

Thu, 30 Jul 2009 00:00:00 GMT

Danielle Scott was a 17 year old girl who had extensive mental health and behavioural problems from about the age of 12. In November 2000 she was referred to Possilpark Health Centre, Glasgow, and was subsequently an in-patient in Gartnavel Hospital for about 15 months. She suffered from bulimia, and engaged in abuse of alcohol and drugs, absconding, self-harming, and sexually promiscuous conduct.

In June 2003 she was placed under the supervision of East Dunbartonshire Council Social Work Department by a Children’s Hearing. In early 2004 she was admitted to the Priory Clinic Glasgow. On 28 April 2004 she was placed in Howdenhall Young Persons’ Centre, Edinburgh, and about 2 months later was moved to the close support unit there. In the autumn of 2004 she attended college, and was employed for a short period. After a drug over-dose in December 2004 she was admitted to Stobhill Hospital, Glasgow for assessment. On 13 January 2005 she returned to the close support unit at Howdenhall.

On 7 February 2005 Danielle left Howdenhall on a one-hour pass. Thereafter she picked up a man named Peter Meaney by making sexual advances towards him. At Meaney’s flat he offered her and she consumed both alcohol and methadone, of which he had a two-week supply. She collapsed and was placed on a bed. Some time between 10 pm on 7 February and 10 am on 8 February 2005 she died, and an ambulance was called (see notes below).

The inquiry determined that her death was due to acute methadone and alcohol poisoning.

In addition, the inquiry considered (1) whether Danielle was suffering from undiagnosed bipolar disorder, in consequence of which she might have been detained under the Mental Health Act 1984, and (2) whether she should have been returned to the secure unit at Howdenhall in the last weeks of her life.

On the first issue the inquiry was of the view that there was insufficient evidence to conclude that she had been suffering from bipolar disorder, but even if she had been, it was unlikely that she would have been detained in hospital, as in-patient treatment was unlikely to have been necessary.

On the second issue the inquiry was of the opinion that the decision taken not to return her to the secure unit, but instead to concentrate on preparing her for independence once she became 18, was amply justified on a consideration of all the circumstances. Therefore, since detention under the Mental Health Act or a return to the secure unit under Social Work legislation would probably not have occurred, the misfortune which befell her might still have happened.

Accordingly the inquiry declined to make any additional determinations or recommendations.

The full Fatal Accident Inquiry report is available at this location:

Fatal Accident Inquiry Rosepark Nursing Home

Thu, 12 Aug 2010 00:00:00 GMT

“The evidence has now been concluded in this Fatal Accident Inquiry. There have been 141 days of evidence. There are 145 lever arch files full of documentary productions. This Inquiry has been noteworthy both in respect of the length of the proceedings and the number and complexity of the issues that have arisen.

Normally, in a Fatal Accident Inquiry, after parties have had the opportunity of studying the notes of evidence, there is an oral hearing to enable parties to propose draft findings in fact that the Sheriff may make, and also to make submissions on the matters required by statute to be determined, namely where and when the deaths took place, the cause or causes of the deaths, or any incident leading to the deaths, the reasonable precautions whereby the deaths might have been avoided, the defects, if any, in any system of working which may have contributed to the deaths or to the incident leading to the deaths, and any other factors considered to be relevant to the circumstances of the deaths.

The issues in this Inquiry are all set out in the Petition which was presented to the court and read out at the commencement of this Inquiry.

In this Inquiry, in my opinion, it is not practicable to hold a full oral hearing at which parties will give their full submissions. In this instance, I think it is appropriate that parties should submit written submissions for my consideration.

I have given careful consideration as to how the question of written submissions should be managed. The Advocate Depute has indicated to the Court that he recognises that the Crown bears a responsibility to assist the Court by presenting full submissions on all the issues which the Court will by statute require to determine. He indicated that he considered it would help to focus the issues which are actively disputed by the interested parties if they can frame their submissions in response to and, as they consider appropriate, under reference to the Crown’s submissions. I agree that it is not appropriate that all parties lodge their submissions at the same time. There requires to be a structure. I think the Crown, who sought this Inquiry, should lodge their draft submissions. Interested parties should then reply thereto and add such other submissions as they wish. As a substantial number of the issues involve several of the interested parties, it is appropriate that all be given an opportunity to adjust their draft submissions in light of the submissions of the interested parties.

I accordingly propose that the exercise should be conducted in four stages:

1. The lodging of draft written submissions on behalf of the Crown, setting out the Crown’s proposed findings in fact and their submissions in respect of the matters which require by statute to be determined by me. These will be intimated to all interested parties.

2. The lodging of draft written submissions in answer on behalf of each of the interested parties, including their response to the Crown’s submissions with, in addition, a note of their own proposed findings in fact and submissions in respect of the matters which require by statute to be determined by me. These submissions will be intimated to all parties, including the Crown.

3. A period of adjustment to allow parties to adjust their draft submissions in light of what has been submitted by the interested parties. It should be understood that interested parties may, in their various submissions, make comments to which other interested parties should, in fairness, be able to respond. Likewise, the Crown would require an opportunity to consider any comments which may be made on its draft submissions with a view, if appropriate, to adjusting its own draft. Written submissions in their final form will then be lodged with the Sheriff Clerk.

4. A short oral hearing in Hamilton Sheriff Court to allow parties to make any final comment and to confirm they have nothing to add. At that time the written submissions will be released to the Press.

I am obliged to the Advocate Depute and to Mr McBride on behalf of the interested parties for their agreement to this proposal and to the following timetable:

1. Draft submissions by the Crown to be lodged with the Sheriff Clerk at Hamilton by 12 November 2010. I accept the submission of the Advocate Depute, which was accepted by all interested parties, that having regard to the volume of the evidence and the complexity of some of the issues which arise, that is a reasonable period for the Crown to do justice to the case.

2. Draft submissions to be lodged by the interested parties with the Sheriff Clerk at Hamilton by 21 December 2010. I consider this gives interested parties a reasonable time to respond to the Crown’s submissions and to make their own submissions.

3. Submissions in their final form, after adjustment, to be lodged with the Sheriff Clerk at Hamilton by 19 January 2011.

4. Oral hearing in Hamilton Sheriff Court on 27 January 2011.

There is a very considerable amount of material that I require to study and digest. This study will be ongoing and will continue as I receive the written submissions in terms of the timetable which I have set out. I am conscious of the many significant issues which have been canvassed at this Inquiry and their importance both to the individuals and organisations involved and in respect of the administration and regulation of Care Homes. These issues demand my careful consideration. I shall do my best to issue my Determination as soon as practicable after 27 January 2011.

I would finally again express the sympathy of all involved to the relatives of those who lost their lives at Rosepark”.

Fatal Accident Inquiry Rosepark Nursing Home

Thu, 20 Jan 2011 00:00:00 GMT

Sheriff Principal Lockhart first received draft written submissions from the Crown which were made available to all interested parties. Interested parties have now lodged draft written submissions in answer. A period of adjustment has been allowed in order that each party may adjust their draft written submissions in light of the material lodged by other parties.

The hearing on 17 February is to give all parties a final opportunity to make any concluding submissions. That hearing may well be relatively brief.

The Sheriff Principal takes the view that the submissions in their final form should be made public. He has decided that the best way to achieve this is to attach an Appendix to his Determination when it is issued. The Appendix will contain all the written submissions which he has received as adjusted and amplified at the hearing on 17 February 2011. That Appendix will be published at the same time as his Determination.

Fatal Accident Inquiry into the death of Danielle Welsh

Fri, 04 Feb 2011 00:00:00 GMT

Having heard evidence over a total of twelve days Sheriff Cubie found that the precautions whereby Danielle’s death could have been avoided were:

• If Dr Das had checked the British National Formulary before prescribing intravenous paracetamol for Danielle on the evening of 17 June 2008.

• If the nursing staff who administered intravenous paracetamol to Danielle between 17 and 20 June had checked that they knew the normal dosage of intravenous paracetamol to be administered, having regard to Danielle’s weight.

• If the Pharmacist Lesley Murray had checked the British National Formulary in respect of intravenous Paracetamol when reviewing Danielle’s drug Kardex in Ward 67.

From the evidence heard Sheriff Cubie found there was, at the time of the death, a prevailing culture of assumed familiarity with the administration of intravenous paracetamol, a familiarity derived from the common use of oral paracetamol. That assumed familiarity was misplaced.

The Sheriff found that there were no defects in the system of working which contributed to the death.

Background

Danielle was born on the 5 June 1989. She had an undefined condition which gave rise to spondyloepiphyseal dysplasia, short stature, mild but longstanding learning difficulties, problems with hearing and chronic pain particularly in the limbs and joints. In June 2008 she weighed 35 kilogrammes.

Given Danielle’s age, the management of her case was in the process of being transferred form Royal Hospital for Sick Children at Yorkhill to the Southern General Hospital (SGH). She was waiting to be seen by the Pain Clinic at SGH.

Danielle became unwell on the 15 June and her parents took her to the SGH.

Tests carried out disclosed a raised white cell count which might point to infection. The presumptive diagnosis was addressed by the administration of anti-viral and antibiotic drugs. Danielle was also prescribed 1g paracetamol “as required”.

On 17 June Danielle was noted to be vomiting by the evening. Oral administration of drugs was accordingly more difficult but she continued to be in pain.

Dr Das, a foundation year one doctor, was asked to prescribe pain relief and anti-emetic drugs. She had had no previous dealings with Danielle and she did not know her weight. She proceeded to prescribe on the basis that Danielle was an adult. In the event, the dosage prescribed, 1g four times daily, was in excess of the appropriate dosage for someone of Danielle’s weight. She should have received 525mg per dosage.

On the 18 June the intravenous administration of paracetamol continued.

On 19 June Danielle’s Kardex was reviewed by Pharmacist Lesley Murray. She may not have seen Danielle in person but she did not alter the prescription. She did not know that the intravenous and oral dosages of Paracetamol were different. She assumed that they were the same. However, Danielle continued to be nauseous, undermining the utility of oral administration of paracetamol. The intravenous administration of paracetamol continued at 1g four times daily.

On 22 June blood tests showed grossly abnormal Liver Function. She was referred to a consultant who, at 23.25pm, referred her to the liver unit at Royal Infirmary of Edinburgh (RIE). There was considerable concern about Danielle’s fitness for transfer.

At 01.30 Danielle was transferred by ambulance to Surgical ITU with acutely deranged Liver Function tests with coagulopathy and raised paracetamol levels. Danielle was in a critical condition but was considered to be likely to survive.

On 24 June 2008 Danielle suffered a cardiac arrest. She was subject to intensive CPR for a period of 35 minutes. but then suffered another heart attack and was pronounced dead at 10.25 am.

Danielle was seen by 11 nurses and 12 different doctors and received 20 doses of paracetamol. The doctors were at all levels and not one of them noted the overdose. No one had appreciated that the intravenous dosage had different parameters from the oral dosage.

What was clear from the Inquiry was that there was a gap in the knowledge of all those who prescribed, administered, reviewed and considered the intravenous paracetamol prescription.

The Sheriff concluded that there was no systemic failure identifiable from the evidence led. The was, however, a prevailing and pervasive failure to appreciate the particular peculiarities of the intravenous dosage of paracetamol, a lack of knowledge and experience shared by the 23 different professionals who dealt with Danielle.

While the three precautions identified are easy to determine with the benefit of hindsight; the accumulation of evidence demonstrated that no professional expressed any concern about the use, or dosage of the intravenous paracetamol. It is unfortunate to single out individual practitioners for attention when they acted intelligibly, if wrongly, given the state of knowledge which prevailed.

There was a prevailing attitude that paracetamol was so familiar that no further enquiry was required., Danielle’s presentation was unusual in terms of her weight in an adult hospital. These factors combined tragically so that she received an overdose on a sustained and regular basis, which led to her death.

The Sheriff further noted that with the tragic and momentous exception of the paracetamol overdose, Danielle received attentive, focused and appropriate care by all the staff throughout her stay in hospital.

The sheriff made no recommendations, although observations were made about the Kardex system which records some patient information, and the drugs administered to the patient

The full determination is now available at this location: http://www.scotcourts.gov.uk/opinions/2011FAI7.html

Fatal Accident Inquiry - Rosepark Nursing Home

Wed, 20 Apr 2011 00:00:00 GMT

The Fatal Accident Inquiry Determination into the deaths at Rosepark Nursing Home is now available along with the written submissions.

Fatal Accident Inquiry into the death of John Aitken

Wed, 17 Aug 2011 00:00:00 GMT

John Aitken died within Ward 14 at Dumfries and Galloway Royal Infirmary, Dumfries on 1 April 2009 at 18.00 hours.

His death was caused by 1(a) Cardiorespiratory arrest (b) Hypoxic brain damage and (c) Widespread severe bronchopneumonia.

The reasonable precautions whereby the death of John Aitken might have been avoided are:

(a) That the instruction to nursing staff in Ward 14 from the Intensive Care Unit physician who was to be responsible for Mr. Aitken in the Unit that Mr. Aitken’s blood saturation levels should be continuously monitored should have been recorded in the nursing notes;

(b) That Mr. Aitken’s blood saturation levels should have been regularly monitored and recorded on his Modified Early Warning System (MEWS) chart by the nursing staff caring for him in Ward 14 before his transfer to the Intensive Care Unit;

(c) That, when it was apparent to the nursing staff in Ward 14 that no portable SATS machine to monitor Mr. Aitken’s blood saturation levels during the transfer was available in Ward 14, the Intensive Care Unit physician who had instructed continuous monitoring of these levels should have been informed;

(d) That the portable oxygen supply to Mr Aitken should have been switched on by the nursing staff responsible for the transfer after he had been disconnected from the wall mounted oxygen supply;

(e) That Mr. Aitken’s blood saturation levels should have been monitored by means of a portable SATS machine continuously throughout his transfer from Ward 14 to the Intensive Care Unit;

(f) That Mr. Aitken should have been observed (seen and looked at) continuously by the nursing staff responsible for his transfer from Ward 14 to the Intensive Care Unit.

The defects in the system of working which contributed to the death of John Aitken were:

(g) There was, in Dumfries and Galloway Royal Infirmary at the time of Mr. Aitken’s death, no formal, properly publicised and fully understood procedure for the care of ill patients during transfers between wards or departments;

(h) Observations of Mr. Aitken’s blood oxygen saturation levels and other information were not recorded on the MEWS chart prior to his transfer;

(i) Mr. Aitken did not receive ambulatory monitoring of his blood oxygen saturation levels during the transfer;

(j) Mr Aitken did not receive supplementary oxygen during the transfer;

(k) Staff on Ward 14 were not fully aware of, and lacked adequate training in, the requirements for the transfer of ill patients such as Mr Aitken from one part of the hospital to another;

The full Determination is now available here.

Fatal Accident Inquiry into the deaths onboard MFV Vision II

Wed, 24 Aug 2011 00:00:00 GMT

In terms of Section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 between 00.30am and 01.30 am on Friday 1st August 2008, Ramilito Capangpangan Calipayan and Benjamin Rosillo Potot died within the galley and Rimants Venckus died within the wheelhouse on board the vessel MFV Vision II BF 190 berthed at Provost Park Jetty, Balaclava Inner Harbour, Fraserburgh. Each of the deaths resulted from a fire which occurred on board the Vision ll.

The deaths of Ramilito Capangpangan Calipayan, Benjamin Rosillo Potot and Rimants Venckus were caused by the inhalation of smoke and fire gases.

The accident resulting in the deaths of Ramilito Capangpangan Calipayan, Benjamin Rosillo Potot and Rimants Venckus was caused by a base unit electric fan heater fitted within a seating unit in the galley of the Vision ll. The air supply to the fan heater was either slowed or stopped by items within the storage area blocking the air vents in the back of the fan heater. This caused the fan heater to overheat. Inside the fan heater are two thermal protection devices. These thermal protection devices are expected to operate if there is an overheating event. If airflow through the air vents is reduced or blocked, the temperature within the fan heater rises. The thermal protection devices ought to respond to the blockage and the increase in temperature by shutting off the fan heater. They did not do so. The temperature of the heating element continued to rise and ignited combustible material within the fan heater which in turn ignited solid combustible items stored within the seating unit.

In terms of Section 6(1)(c) of the Act, the reasonable precautions by which the accident and the deaths might have been avoided are as follows:

(a) The fan heater, which had been installed when the Vision ll was built, should have been housed within a suitable plywood box.

(b) Combustible items should not have been stored in close proximity to the fan heater.

(c) The self-closing mechanism on the fire door separating the galley from the passageway should not have been disabled and that door should not have been kept permanently open through the use of a hook and eye device.

(d) Crew members should have been provided with adequate training and undertaken regular emergency drills in the action required of them in the event of an emergency.

(e) Regular inspection and maintenance of emergency exits should have been undertaken.

(f) The fire detection system should have been wired in such a way as to prevent it being turned off.

(g) The fire detection system should have been connected to a secondary power source lest the main power failed or was turned off.

(h) Labels should have been attached to the circuit breakers relating to the fire detection system instructing the crew that the circuit breakers were not to be powered off.

(i) Additional fire alarms should have been fitted in the galley, the passageway and the cabin space.

The full Determination is now available

Fatal Accident Inquiry into the deaths of Erin Casey and Christina Fiorre Ilia

Thu, 25 Aug 2011 00:00:00 GMT

Erin Casey, aged 19, died on 27th October 2006 within her bedroom, Room 5, 22 Fife Park, St Andrews, Fife.
Christina Ilia, aged 15, died on 23rd March 2009 at 19 Newmonthill, Forfar, Angus.

Erin and Christina were the much loved daughters of caring and supportive parents. Erin had two loyal siblings, a brother and sister, and was in a fond relationship with her boyfriend.
Erin was an intelligent, hard working young woman who was in the first year of a degree course in languages at St Andrews University.

Christina had been born with various medical difficulties but through her own fortitude and the support of her parents she had grown up to be a popular, bright schoolgirl undertaking a wide range of school and community activities.
Erin and Christina had much to live for and are sadly missed.

Between November 2010 and March 2011 a Fatal Accident Inquiry was held into the circumstances of both deaths. The purpose of the inquiry was firstly to ascertain the circumstances surrounding the deaths of Erin and Christina, including the cause of death, and also to establish whether there were any reasonable precautions which, if taken, might have avoided Erin and Christina dying in the circumstances in which they did.

(“Certainty that the accident or death would have been avoided by the reasonable precaution is not what is required. What is envisaged is not a “probability” but a real or lively possibility that the death might have been avoided by the reasonable precaution” Carmichael, Sudden Deaths and Fatal Accident Inquiries 3rd Edition page 174 para 5-75.)

Summary of Findings

In respect of both Erin and Christina the cause of death was sudden unexpected death in epilepsy (SUDEP).

In relation to Erin

(1) The reasonable precautions whereby the death might have been avoided were
if Erin and her parents had been advised of the risk of SUDEP;
if Erin had adhered to the regime of anti-epilepsy medication prescribed to her; and
if Erin had been subject to supervision while asleep during the night of 27th October;
(2) A defect in any system of working which contributed to the death was:-
Erin’s response to her initial diagnosis, understanding of that
diagnosis and compliance with medication was not effectively monitored and appropriate further advice was not provided in the period immediately after 12th April 2006 and before her next appointment on 5th September 2006 and between then and her death;
(3) Other facts which were relevant to the circumstances of the death were:-
No system was in place within Erin’s GP practice to monitor her
uptake of the repeat prescription of her anti-epilepsy medication

In relation to Christina

      (1) The reasonable precautions whereby the death might have been
      avoided were:-
                (a) if Christina and her parents had been advised of the risk of SUDEP;
                (b) if Christina had been subject to supervision while asleep during
                      the night of 23rd March;
(2) Other facts which were relevant to the circumstances of the death were:-
Officers of Tayside Police who attended at Christina’s home on the morning of her death referred to the house as “a crime scene” in speaking to her parents. This was insensitive and, if it accords with procedure, should be reconsidered in future.

I recommend the following:-

The vast majority of patients with epilepsy, or their parents or carers where appropriate, should be advised of the risk of SUDEP on first diagnosis or if , in the particular circumstances of that patient, there are exceptional circumstances for delaying immediate provision of the information, then within a very short time thereafter. Advice about the risk of SUDEP should only be withheld if there is assessed to be, in the case of a particular patient, a risk of serious harm to the patient in providing the information or the patient has learning difficulties.
A decision not to inform a patient or his or her family about
SUDEP should be recorded in the patient’s medical records alongwith an explanation, however brief, for the decision.
After a consultation with an epilepsy patient the consultant or, where appropriate, the specialist epilepsy nurse, should send a letter to the patient and to the patient’s GP summarising the findings of the consultation and any care or treatment decisions taken.
The information and advice about SUDEP should be provided directly by the consultant in charge of the patient’s case or, where appropriate, by an epilepsy specialist nurse.
All NHS Boards should prioritise consideration of their arrangements for the care of epilepsy patients, whether a post of epilepsy specialist nurse is required, if not already in place, in any particular hospital and, if there is such a post, whether the current arrangements are adequate.
Current arrangements for the provision of written information packs to newly diagnosed epilepsy patients and their families should be reviewed to ensure that they are adequate and meet the needs of patients for information and access to services and support at a distressing time.
Where a patient is prescribed medication both the prescribing doctor and the dispensing pharmacist should provide the patient with clear and easily understood instructions as to how the medication is to be taken. If the regime of medication is relatively complex the doctor should take time to explain it and should, in particularly complex cases, provide written instructions. In the case of all prescriptions pharmacy labels should be clearly printed in easily read, jargon-free text.
Consideration should be given to the feasibility of introducing a
     system in GP practices (possibly in conjunction with pharmacies)
     whereby the uptake of repeat prescriptions by patients can be
     monitored.

Those responsible for the issuance of guidelines on the care and management of epilepsy patients should consider the adequacy of existing guidelines in the light of this inquiry and the evidence led. They should consider the recommendations made, any resultant revision of the guidelines which might be appropriate and the need for clarifying for medical professionals the status of the guidelines in clinical practice.
It may be that some of my recommendations, if adopted, would have ramifications for training of medical professionals. Regardless of such consequential issues of training it appeared to me that this inquiry revealed other areas of clinical practice in respect of which I recommend that consideration be given to the training needs of medical professionals:-
the assessment of published research literature;
the status of published guidelines on care and treatment;
the provision of potentially distressing information to patients;
methods for obtaining information from patients, particularly teenagers or those who may be reluctant to be honest with their doctor or nurse;
the provision of information and advice about modifying behaviour to achieve lifestyle changes which may contribute to the relief of a condition or minimise a risk associated with that condition;
recognising the particular circumstances of a patient and tailoring advice and information as appropriate with particular emphasis on teenagers or young adults moving towards independence, engaging in risky activities or beginning to take responsibility for themselves.
(10) I recommend that Tayside Police and, if appropriate, other forces,
       review their practice in relation to their approach to the location of a
       sudden unexpected death and in particular the practice of, ab initio,
       describing it as a “crime scene”.

Fatal Accident Inquiry into the deaths of Colin McRae, Graeme Duncan, Ben Porcelli and John McRae

Tue, 06 Sep 2011 00:00:00 GMT

This is an Inquiry instituted by the Lord Advocate under the discretionary provisions of the Fatal Accidents and Sudden Deaths Inquiries (Scotland) Act 1976. It was considered expedient in the public interest that such an Inquiry should be held into the circumstances of the deaths of Colin Steele McRae, aged 39, Graeme Arthur Duncan, aged 36, Ben Telfer Porcelli, aged 6 and John Gavin McRae, aged 5, which occurred when the helicopter piloted by Mr McRae and in which they were passengers crashed on 15 September 2007.

The Inquiry took place at Lanark Sheriff Court and evidence was heard over 16 days between 12 January and 26 May 2011 with final submissions heard on 8 August 2011. A locus inspection of the crash site and points along the helicopter’s final flight path took place on 25 January 2011.

Graeme Duncan filmed much of the outbound and return flights on his personal camcorder. 5.3 minutes of video and sound track were recovered in total. The video was taken from his front passenger seat and ended approximately 55 seconds prior to the accident. This source provides confirmation from pre-flight checks at the start of the outbound journey that all engine and system indications were normal and flight instruments appeared serviceable.

The video recording provides detailed information as to the manner in which Mr McRae piloted G-CBHL that day. He consistently flew the helicopter at unnecessarily low heights. He clearly breached the 500 feet minimum separation requirement on at least one occasion when he detoured to fly at 275 feet over farm buildings and may well have done so on others. He undertook significant manoeuvring at low level and the helicopter seems to have encountered significant g-loading as a result, to the evident enjoyment of his passengers.

The episodes of extremely low level flying and the excessive manoeuvre parameters, particularly the descent into the valley by Larkhall, all as captured on the video recording, are indicative of an aircraft being flown imprudently, without due regard to the principles of good airmanship, and in such a way that normal safety margins would be reduced.

The deaths and the accident resulting in the deaths might have been avoided had Mr McRae not flown his helicopter into the Mouse Valley. Such a precaution would have been entirely reasonable. There was no necessity to enter the Mouse Valley. There were no operational or logistical reasons to enter the Mouse Valley. Mr McRae chose to fly the helicopter into the valley. For a private pilot such as Mr McRae, lacking the necessary training, experience or requirement to do so, embarking upon such demanding, low level flying in such difficult terrain, was imprudent, unreasonable and contrary to the principles of good airmanship.

In order to pilot an aircraft in the UK it is necessary to hold a pilot’s licence, a valid relevant medical certificate, to have had the pilot’s licence validated with the type of aircraft to be flown and to hold a Licence Proficiency Check (“LPC”) in respect of the type of aircraft to be flown. On the date of the accident Mr McRae possessed the necessary medical certificate but did not hold a valid flying licence or a valid AS350B2 type rating. He was accordingly in breach of Article 26 of the Air Navigation Order 2005 when he flew his helicopter on 15 September 2007 and should not have flown that machine at that time.

In terms of section 6(1)(c) of the Act it would have been a reasonable precaution to refrain from flying helicopter G-CBHL into Mouse Valley wherein the pilot engaged in low level flying when it was unnecessary and unsafe for him to do so and whilst carrying passengers on board. The accident occurred when, due to an unknown occurrence, the aircraft deviated from its intended flight path and crashed into trees lining the side of Mouse Valley. Whatever happened was sudden, unexpected and took place in circumstances where Mr McRae did not have scope to recover.

The aircraft was in powered flight at the time of the collision and attempts were being made by Mr McRae to recover from that unknown event. These attempts were rendered ultimately unsuccessful because of the position and speed of the helicopter within Mouse Valley and the resultant restrictions on opportunity to land or fly the helicopter to safety.

Such options would have been available to him had he adhered to rules of good airmanship and desisted from flying in the valley at low height and high speed.

The full Determination is available here.

FAI into deaths of CRAIG CURRIE, WILLIAM CARTY, STEPHEN CARTY and THOMAS DOUGLAS

Mon, 10 Oct 2011 00:00:00 GMT

The inquiry into the deaths of Craig Currie, William Carty, Stephen Carty and Thomas Douglas took place at Oban Sheriff Court between 1 June 2010 and 11 January 2011.

Following consideration of the evidence and submissions to the Inquiry Sheriff Small made the following findings:

The deaths might have been avoided if.

The deceased had been wearing fully functional and properly secured and fitted lifejackets.
The deceased had taken responsibility for their own safety and had taken into account the prevailing weather conditions, the lack of visibility and potential hazards on Loch Awe before embarking in their boat onto the loch.
The deceased had returned to the Tight Line public house to obtain a lift back to their campsite.
The deceased, as well as phoning their friend Edward Colquhoun from their boat, had phoned emergency services.
The deceased had not consumed alcohol prior to taking the collective decision to take their boat onto the loch.

The other facts which Sheriff Small considers to be relevant to the circumstances of the deaths are:

There was no register of local assistance (ROLA) available to be called upon by the rescue services at the time of the accident.
That there were communication difficulties for the emergency services in attendance. There is now a digital based system of communications in operation (Firelink System) which enables communications within the fire services, the police, and ambulance and resilient teams. This system does not extend to Maritime Coastguard Agency (MCA) personnel or to the mountain rescue services.
Individual crew members of Strathclyde Fire Service were not at the time of the accident personally equipped with lifejackets.
Those members of Strathclyde Fire Service who were the first to arrive at the campsite of the deceased did not source and communicate to their boat crew a suitable launch site.
The Strathclyde Fire and Rescue boat was not equipped with physical markers to assist in identifying accurately those areas of the loch where debris and the bodies of Craig Currie and William Carty had been retrieved.

Further recommendations

That a register of local assistance which excludes the ambulance service be made up by Strathclyde Police and circulated to the emergency services and that the register includes the names of persons and equipment available to be called upon in an emergency rescue situation.
That in the event of an emergency involving Strathclyde Police and the MCA, Strathclyde Police should provide MCA personnel with a police radio for communication purposes.
That all Strathclyde Fire Service vehicles should be equipped with a lifejacket for each individual crew member.
That Strathclyde Fire and Rescue boats carry markers to assist in identifying areas of water from which debris or bodies of deceased are located.
That in a water based incident there be a protocol in place whereby there is communication between the boat crew and those crews in attendance at the location of the incident.

In the absence of the boat used by the deceased being recovered or any direct evidence as to what caused it to sink the Inquiry was unable to make any specific findings about that matter.

In finding that the deceased deaths might have been avoided had they not consumed alcohol before going onto the Loch the Inquiry took into account the evidence of drink consumed by the men before they left for the Tight Line public house and also the evidence of how much drink was consumed there. In addition, the opinion evidence provided by Professor Michael Tipton suggested that the deceased’s assessment of risk may have been impaired by their consumption of alcohol.

The Inquiry found no evidence to suggest any criticism of the emergency services or the systems of work employed by them at this very tragic accident. Their individual responses and the manner in which they carried out their duties in extremely difficult conditions were commendable.

Read the full Determination

Fatal Accident Inquiry into the death of Margaret Allison Hume

Wed, 16 Nov 2011 00:00:00 GMT

Margaret Allison Hume was pronounced dead at Kilmarnock at 7.40 am on 26 July 2008, having been extracted from a collapsed mine shaft, attached to a decommissioned colliery known as Goatfoot Colliery, situated at Barrwood Gate, Galston. Mrs Hume suffered death after a prolonged period at the base of the mine shaft into which she had stepped shortly before or after midnight on 25 July 2008.

It took between 5 to 6 hours for Mrs Hume to be uplifted from the collapsed mine shaft from the time of arrival of Strathclyde Fire and Rescue Service. She had probably been in the shaft for about 2 hours before their arrival. By the time she was brought to the surface at 7.42am she was profoundly hypothermic. Her core body temperature was 24 degrees, 13 degrees below normal. She was in a critical physical condition having suffered a pneumothorax, broken ribs and a broken sternum.

The Inquiry arose from circumstances where the Lord Advocate considered it expedient and in the public interest. She petitioned the Sheriff Court for a warrant to do so on the grounds that the death of Mrs Hume was sudden, or suspicious, or unexplained, or had occurred in circumstances which had given rise to serious public concern.

This Inquiry is an examination of the circumstances of her fall and the rescue effort to save her.

Sheriff Leslie found that the death of Margaret Allison Hume may have been avoided had the following reasonable precautions been taken:

Early identification by the Police and Strathclyde Fire and Rescue Services of the stability of the mine shaft and surrounding area
Early assessment of Mrs Hume’s medical condition, and appraisal of the likely dangers of a prolonged stay in cold and wet conditions,
A thorough understanding of the capability and properties of line rescue equipment known as safe working at height (SWAH) equipment, and the level of training of fire fighters in the use of that equipment,
A rigorous and thorough risk assessment by Strathclyde Fire and Rescue Service balancing the conditions of the terrain with the condition of the Deceased and the passage of time to have prevailed over restrictive Strathclyde Fire and Rescue Service Corporate Policy,

Defects in the system of working which contributed to the death, or the accident resulting in the death of Margaret Allison Hume:

Inadequate knowledge by Strathclyde Fire and Rescue Service and The Police of the range of potential rescue resources available to assist in a rescue operation and consequent failure to communicate with these resources.
Lack of understanding and familiarity by rescue personnel of the potential for use of the differing medical and rescue equipment supplied to the rescue and emergency services.
Lack of multi-ability training for emergency services personnel, and in particular lack of advance first aid training among Fire and Rescue Service personnel, lack of rope access capability amongst Fire and Rescue personnel and paramedical personnel
Over reliance on the delegation of rescue functions by Strathclyde Fire Rescue Service.
Inadequate pre-planning for mine and mine shaft rescue

The other facts relative to the circumstances of the death or the accident leading to the death:

There should be continuous assessment of emergency and rescue resources by all rescue and emergency agencies and the capabilities of these resources regularly communicated throughout senior and junior management of each agency.

Sheriff Leslie acknowledged Mr Alexander Dunn’s bravery and selflessness in volunteering to provide succour to Mrs Hume as she lay at the bottom of the collapsed mineshaft. He also acknowledged the very considerable effort made by Mr Andrew Parker of Strathclyde Police Mountain Rescue Team who with Mr Dunn brought Mrs Hume to the surface. They were supported by colleagues from Strathclyde Fire and Rescue Service, Strathclyde Mountain Rescue Team and the Scottish Ambulance Paramedical team, and all, despite their frustrations and anxieties, endeavoured to do their best in very difficult circumstances to rescue and save Mrs Hume.

“I extend the sympathies of the Inquiry to Mrs Hume’s family who acted with great dignity and stoicism in the face of some very harrowing evidence”.

Sheriff Leslie

Read the full Determination.

FAI into the deaths of Agnes Nicol, George Johnstone and Andrew Ritchie

Thu, 16 Feb 2012 00:00:00 GMT

A Fatal Accident Inquiry into the death of Mrs Agnes Nicol was held at Cumbernauld between 24th October and 16th November 2011. At the same time the Inquiry was asked to consider evidence in relation to the deaths of Mr George Johnstone and Mr Andrew Ritchie.

On 23rd November 2010 the Procurator Fiscal at Airdrie, on behalf of the Lord Advocate, petitioned the Court to hold this joint inquiry in terms of Section 1(1)(b) of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976. It was considered to be in the public interest to hold an inquiry into three deaths which had occurred in a three month period in 2006 following, in each case, a laparoscopic cholecystectomy (keyhole gallbladder removal) in a Lanarkshire hospital. The evidence established that cholecystectomies are one of the most common operations carried out and there was natural concern when on three separate occasions patients died following such an operation.

Agnes Nicol died within Ward 118 Intensive Therapy Unit, Edinburgh Royal Infirmary at 12:57pm on 10th March 2006. The cause of death was multiple organ failure due to recurrent septicaemia due to hepatic infarction due to complications of endoscopic chlolecystectomy carried out on 22nd December within Wishaw General Hospital. The complications were caused by a misidentification of the anatomy by a Staff Grade Surgeon who wrongly cut the common bile duct and right hepatic artery and the subsequent suturing of the portal vein by a Consultant Surgeon cutting off 80% of the blood supply to the liver. (see paras 16 and17) These mistakes were not discovered until Mrs Nicol was transferred to the Liver Unit at Edinburgh Royal Infirmary.

No attempt was made at Wishaw Genera Hospital to investigate why she was deteriorating and the Consultant did not record anything in the medical notes. He ignored the exceptionally high ALT figures (Para 24) which showed a major liver problem until the evening of 28th December. By the time Mrs Nicol was sent to Edinburgh her liver was so badly damaged that she died there.

George Johnstone died within the intensive care unit, Monklands District General Hospital, Airdrie at 7:55pm on 11th May 2006. The cause of death was multiple organ failure due to a biliary leak following laparoscopic cholecystectomy carried out on 9th May 2006 within Monklands District General Hospital by a Consultant General Surgeon and that a secondary cause was ischemic heart disease. The biliary leak arose due to the Consultant either cutting or damaging the main bile duct. (Para 13). The cause of Mr Johnstone’s deteriorating health post operatively was not investigated by the Consultant Surgeon despite a junior doctor specifically querying whether there was an abscess and seeking Consultant advice at 4.30am on 11th May (Paras 28 – 35). He did not return the patient to surgery when a scan at 11 30am showed fluid around the liver and within the pelvis (Para 44) Professor Garden from Edinburgh Royal Infirmary in his evidence stated that, had this been his patient, he would personally have pushed the patient’s bed into the operating theatre to minimise any delay (page 46).

Mr Andrew Ritchie died within the Intensive care unit, Wishaw General Hospital at 3pm on 23 June 2006. The cause of death was an intra abdominal haemorrhage due to dehiscence of the duodenal surgical site due to a laproscopic cholecystectomy due to chronic cholecystitis. The duodenal perforations occurred during or as a direct result of the surgery carried out by a Consultant General Surgeon on 14 June (para 20). No investigation took place until 20 June to ascertain why there was a continuous discharge of bile from the operation site. Despite the Consultant herself recording the possibility of a duodenal perforation (para 32) on 16th June no scan or operation followed.

The Inquiry found that there were individual circumstances in relation to each of the deaths and errors made in surgery and in particular the post-operative care of the patients which caused those deaths. They involved different Consultant Surgeons and there is no evidence that there was a lack of training or experience in the Surgeons involved.

Although the evidence established that the circumstances of each death was different, and the complication which arose in the course of the surgery which led to the patient’s death was different in each case, there are certain factors which are common to at least two if not all of the deaths which require to be commented on. These are:

• The failure to ensure the filing of all reports within the hospital records.

• The rota system which existed in 2005 (but which has been subsequently changed) whereby a patient admitted as an emergency becomes the responsibility of the consultant on duty on the day of admission. This was not withstanding the fact that there could be other consultants within the hospital staff who had a greater expertise or experience in the relevant field of surgery.

• The policy which existed in 2005 that a patient displaying major gall bladder problems on initial admission to the hospital would almost invariably be treated conservatively and expected to return at a later date for an elective operation.

• The failure of the surgeons to consider the possibility that there had been a misidentification of the structures or that structures had been damaged in the course of the operation. This was the cause, or was significantly contributory, to each patient’s failure to recover (pages 39 -40 Andrew Ritchie).

The evidence before the Inquiry showed that at the time the lack of a complete set of records and documents in relation to any of the three patients was indicative of a system which requires to be overhauled. (page 42 Andrew Ritchie)

It is essential that every doctor and nurse responsible for the care of a patient has access to all the records and all the documents and that full notes are available at all times. In relation to the care of Mrs Nicol, Mr Johnstone and Mr Ritchie this was not so.

NHS Lanarkshire should ensure in future that there is full documentation recorded by both the doctors and nurses involved in each stage of the treatment of patients, and that the records department ensures that all the hospital records are kept and made available to all those who require access to them. In all 3 cases this had not happened. (pages 40 – 42, Andrew Ritchie)

In his assessment of the records and reports in relation to the three deaths Professor James Garden of Edinburgh Royal Infirmary highlighted three matters. (pages 36 -39, Andrew Ritchie)

• The management of the initial presentation;

• The management of the post-operative period; and

• The mistaken and apparent unswerving belief of the surgeons that any failure of the patient to respond post-operatively as expected, could not be due to any complication attributable to the operation itself.

Only in relation to the management of Mr Ritchie was this criticism rejected and only in so far as it related to the management of the initial presentation.

Read the full Determination here.

Fatal Accident Inquiry into the death of Gordon Stewart Lennon

Tue, 21 Feb 2012 00:00:00 GMT

A Fatal Accident Inquiry into the death of Gordon Stewart Lennon, born 15 February 1983, has found that the cause of death was electrocution. At the time of his death Mr Lennon was a part-time professional footballer with Dumbarton Football Club.

On Friday 5 June 2009, Mr Lennon arrived in Inverness with his family. They were visiting his fiancée’s sister Sarah Hampton and her husband James Hampton for the weekend. They were due to stay in Inverness until Monday 8 June 2009.

During the weekend, Mr Hampton received a call from his friend Fraser Hughes inviting him to go off-road driving at the Brahan Estate on Sunday 7 June 2009. He initially declined due to Mr Lennon's visit. However, having discussed the matter with Mr Lennon, Mr Hampton telephoned Mr Hughes and asked if both Mr Hampton and Mr Lennon could come along to the Brahan Estate on the Sunday. Arrangements were made for Mr Hampton and Mr Lennon to attend. Mr Hampton was to be a passenger in the vehicle of John Martin, Mr Hughes' brother. Mr Lennon was to be a passenger in Mr Hughes' vehicle. The deceased had no experience in off-road driving.

A Fatal Accident Inquiry found that the cause of the accident which led to Mr Lennon’s death was that the vehicle, a Mercedes-Benz G-Wagon 230 GE 4 wheel drive motor vehicle, driven by Fraser Hughes, in which the deceased was a passenger, was travelling too fast for the conditions on a track within a wood in Brahan Estate in the vicinity of an obvious electricity pole. The vehicle struck the wooden electricity pole which was broken by the impact of the collision. That caused the conductors or power lines to drop. One of the conductors became caught under the front bumper of the vehicle and shortly thereafter electricity passed through Mr. Lennon’s body.

The accident would have been avoided if Fraser Hughes, the driver of the G-Wagon, had firstly driven with sufficient care and attention and maintained proper control of his vehicle and secondly if he had driven at a lower speed appropriate to the conditions as he approached the electricity pole.

The electricity pole which was struck and the local electricity grid and supply it supported was operated by Scottish Hydro Electric Power Distribution Limited (‘Scottish Hydro Electric’). There were no defects either in the equipment or in the system operated which had a material impact on the accident. There can be no criticism of the delayed auto reclose relay feature set up to restore power after the system had automatically tripped off the live supply when it detected a sudden disruption or surge in the current. The circumstances of the accident involved several such episodes of tripping off and reclosing of the supply before the supply at the locus was finally switched off. The statutory and other responsibilities and duties owed by Scottish Hydro Electric to their customers including customers who may have been harmed or prejudiced by sudden withdrawal of electrical power required such a system to be in place so that a transitory event, such as tree branches touching a line in high winds, did not result in the entire area, which in this case covered several thousand businesses and homes, being cut off.

The off-roading activity fell outwith the scope of the Health & Safety at Work etc Act 1974 because of the way it was organised and the status of the parties involved and could not therefore be regulated by the Health & Safety Executive. The sheriff recommends that the Highland Council consider whether off-road events which are open to the public and involve some form of commercial payment should be included in the list requiring a public entertainment licence in terms of section 41 of the Civic Government (Scotland) Act 1982 .

The sheriff further recommends that Northern Constabulary review its policy on the investigation of vehicle collisions which do not occur on the public highway to ensure, so far as practicable, that evidence is appropriately and timeously gathered and preserved.

The evidence presented during the FAI described a terrifying sequence of events. While all of those present immediately after the accident did what they could to assist Mr. Lennon the sheriff praised the conduct of Mr. James Hampton, who it seems had no regard for his own safety and jumped over what may have been a live electricity conductor in order to try to rescue Mr. Lennon and to carry out CPR on him until the arrival of the ambulance personnel.

“Mr. Lennon’s death can only be described as tragic and untimely. I offer my personal condolences to all of his family”. Sheriff Alasdair MacFadyen

The full Determination can be found here

Fatal Accident Inquiry into the deaths on Erskine Bridge

Tue, 01 May 2012 00:00:00 GMT

Niamh Frances Bysouth (also known as Niamh Frances Lafferty) and Terrie Faye Oliver (also known as Georgia May Rowe) died in the waters of the River Clyde below the Erskine Bridge Renfrewshire shortly before 21.00 on Sunday 4^th October 2009. Their deaths were suicides. The girls, having walked from the Good Shepherd Open Unit stopped at a point near the centre of the Bridge, at the barrier on the west side. Both girls died on impact with the water.

Evidence in the Inquiry began on 15^th June 2011 and the Inquiry heard from the last witness on 19^th December 2011. Evidence was heard over some 65 days.

The deaths of Niamh Frances Bythsouth (also known as Niamh Frances Lafferty) and Terrie Faye Oliver (also known as Georgia May Rowe) may have been avoided had the following reasonable precautions been taken:

Had the number of staff members on duty at the Good Shepherd Open Unit on 4^th October 2009 been at least four in terms of Regulation 13 of SSI 114/2002, the agreement between the provider and the Scottish Commission for the Regulation of Care (‘the Care Commission’), and in light of the prevailing dynamics within the establishment.
Had Niamh Frances Bysouth (also known as Niamh Frances Lafferty) and Terrie Faye Oliver (also known as Georgia May Rowe) been accommodated in October 2009 on the first floor of the Good Shepherd Open Unit rather than in the self-contained flat on the ground floor directly opposite an unalarmed fire exit door

The following facts are relevant to the circumstances of the deaths:

There was a need for a more robust approach to the issue of absconding linked to the security of the premises at the Good Shepherd Open Unit
Management at the Good Shepherd Open Unit in August, September and October 2009 should have given proper regard to the serious nature of the bullying of Terrie Faye Oliver (also known as Georgia May Rowe) by AM (a young person resident in the establishment at the time) and its impact on Terrie Faye Oliver (also known as Georgia May Rowe) and management should to have taken appropriate steps to ensure the removal of either Terrie Faye Oliver (also known as Georgia May Rowe) or AM from her placement at the Good Shepherd Open Unit
The failure of placing authorities to hold detailed, comprehensive, concise and readily accessible information relating to an individual child to include the recommendations of the child’s social worker/key worker and any psychological assessment, and to ensure this information was copied to the residential establishment on any placement of the child.
There was a need for systems of communication (both verbal and documentary) to be set up and adhered to by all staff responsible for the care and safety of young persons to ensure that accurate and up-to-date information relating to an individual child was available to decision makers and to those responsible for day-to-day care
The need for a ‘stand alone’ risk assessment in documentary form for each young person in the care of a residential institution with separate consideration given to the issues of ‘self-harm’ and ‘suicide’.

No ‘stand alone’ risk assessment was ever done on either Niamh or Georgia by their placing authorities nor by any of the residential establishments in which they were placed. Had such an assessment been carried out, regularly updated, and accompanied each girl to the various establishments in which she was placed, then management and staff charged with their health and safety would have had a readily accessible and comprehensive document as a valuable tool to assist them in their responsibilities and to alert them to the risks which pertained, whether those were in relation to absconding, self-harm or suicide.

The Inquiry heard from Professor Stephen Platt, Professor of Health Policy Research at the Centre for Population Health Sciences at the University of Edinburgh. One area of concern for him was why, given the case histories of both Niamh and Georgia, no judgement as to the risk of suicide was ever reached by those in the Open Unit. In his conclusion he makes three preliminary recommendations which may benefit those responsible for the welfare and safety of young persons in their care.

1. Local authorities should commission a set of guidelines for staff working with looked after and accommodated children about recognising and mitigating suicide risk in this client group. These guidelines should include the requirement to develop a detailed management protocol.

2. The management protocol should set out the procedures to be implemented when a looked after and accommodation child is considered to be at risk of self-harm or suicide e.g. by making suicide ‘threats’, by expressing suicidal thoughts or by making preparations for suicide. The protocol should cover inter alia the allocation of duties and responsibilities, effective methods of communication, within the establishment, liaison with other professionals and techniques for preventing contagion/spread of suicidal behaviour within the establishment.

3. Professionals working with looked after and accommodated children, either directly (e.g. in residential establishments) or indirectly (e.g. local general practitioners or employed in the local CAMHS team0 should have a sound understanding of the risk of self-harm and suicide among their clients and of appropriate interventions to mitigate that risk. Appropriate training should be provided on starting employment in a residential centre and at regular intervals thereafter (as part of continuing professional development).

“I would wish once more to express my sympathy to the families of Niamh and Georgia and to put on record how grateful I am for the way in which those who attended the Inquiry conducted themselves throughout, both in the giving of evidence, and in the way they conducted themselves during the many days of evidence, much of which must have been distressing for them all. They behaved with dignity and restraint throughout”. Sheriff Ruth Anderson QC

The full Determination is now available here.