2012 FAI 32
Sheriffdom of Grampian, Highland and Islands at Peterhead
DETERMINATION
By
Gregor Kenneth Murray, Sheriff of the above court following an Inquiry held at Peterhead on 12th June 2012 into the death of PETER IRELAND, then in legal custody at HM Prison Peterhead
Peterhead, 13th June 2012
The Sheriff, having considered all the evidence adduced, determines:-
1. In terms of Section 6(1)(a) of the Fatal Accidents and Inquiries (Scotland) Act 1976 that the said Peter Ireland died at approximately 15.15 hours on 1st January 2012 in Aberdeen Royal Infirmary, Aberdeen.
2. In terms of Section 6(1)(b) of the Fatal Accidents and Inquiries (Scotland) Act 1976 that the cause of death of the said Peter Ireland was natural causes, namely coronary artery thrombosis.
Note
Evidence in this inquiry into Mr Ireland's death was heard on 12th June 2012. The Crown was represented by Mr Fay, Procurator Fiscal Depute, Peterhead. The Scottish Prison Service was represented by Miss Nicholson, Solicitor, Edinburgh. I was advised by Mr Fay that solicitors acting for the Scottish Prison Officers Association had intimated they did not intend to appear and that the Inquiry had been intimated to Mr Ireland's family, who had not responded.
The evidence led was formal, consisting of a Joint Minute read into the Record by Mr Fay. The Joint Minute incorporated a Report by Doctor Grieve dated 23rd January 2012, following an autopsy on 4th January 2012 which he carried out.
The evidence disclosed Mr Ireland had been a prisoner at HMP Peterhead since 22nd January 2008, having received a nine year sentence of imprisonment with effect from 21st September 2007. His medical history then related mainly to treatment he had received as a sufferer of Hirschsprung's disease since his mid twenties.
On 18th December 2011, Mr Ireland complained of chest pains and shortness of breath. He was taken to a local hospital and prescribed Amlodipine as it was suspected he was suffering from Angina.
On Sunday 1st January 2012, Mr Ireland was seen and spoken to several times between 7.45 and 11.15 hours by prison officers and another prisoner, Mr West. Although he was still in bed, about 11.10 hours Mr Ireland told Mr West he would get up to eat lunch in his cell. When Mr West returned shortly after with his lunch, Mr Ireland was dressed, sitting on his bed and holding his chest. He then slumped forward unconscious on to the floor of his cell. A prison officer and nurse were called, who provided first aid and called an ambulance. Before the ambulance arrived, Mr Ireland briefly regained consciousness. He was reassured and an oxygen mask applied. However, after his eyes rolled thereafter, he was placed in the recovery position. His breathing then slowed before stopping altogether, leading to CPR being commenced. Mr Ireland's breathing recommenced before paramedics arrived. They applied an ECG scan, which showed Mr Ireland had suffered a heart attack. Consequently, he was taken by ambulance to Aberdeen Royal Infirmary. En route, Mr Ireland's breathing stopped twice more. On the first occasion, CPR administered by the paramedics led to breathing recommencing. However, on the second occasion CPR was ongoing when the ambulance arrived at ARI at 13.07 hours. Resuscitation measures continued there under supervision of medical staff. Despite these, Mr Ireland did not recover. A decision was taken to cease further efforts at 13.22 hours. At 15.15p.m., due to extreme workload at the time, life was pronounced extinct by the supervising Doctor.
Sheriff