INQUIRY UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF ANTONY SCOTT FISHER STORRIE
SHERIFFDOM OF NORTH STRATHCLYDE AT PAISLEY
[2016] FAI 21
B27/16
DETERMINATION
By
SHERIFF PRINCIPAL DUNCAN L MURRAY
UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRIES (SCOTLAND) ACT 1976
into the death of
ANTONY SCOTT FISHER STORRIE
PAISLEY , 9 NOVEMBER 2016
The Sheriff, having heard and considered all of the evidence, and the submissions of parties, finds and determines that:
[a] In terms of section 6 (1) (a) of the Fatal Accidents and Sudden Deaths Inquiries (Scotland) Act 1976:
Antony Scott Fisher Storrie, born 22 January 1988 and who resided at Flat 3/1 Townhead Terrace, Paisley, died in the Intensive Care Unit, at the Royal Alexandria Hospital Paisley at 3:50pm on 30 June 2013.
[b] In terms of section 6 (1) (b) of the Act:
The cause of the death of Antony Scott Fisher Storrie was: Intra-abdominal haemorrhage, due to liver laceration, due to blunt force trauma. This was the cause of death recorded in the post-mortem report Crown Production 11. The cause of the blunt force trauma resulting in the death of Antony Scott Fisher Storrie was, on the balance of probabilities an accidental injury sustained by Mr Storrie while under the influence of 251-NBOMe (n-bomb).
[c] In terms of section 6 (1) (c) of the Act the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided:
A reasonable precaution by which the death may have been avoided would have been if Mr Storrie had refrained from the consumption of n-bomb.
[d] In terms of section 6 (1) (d) of the Act the defects, if any, in any system of working which contributed to the death or any accident resulting in the death:
There were no defects in any system of working which contributed to the death.
[e] In terms of section 6 (1) (e) of the Act any other facts which are relevant to the circumstances of the death:
As a result of Mr Storrie’s consumption of n-bomb he was unable to provide a history of trauma. There was no evidence of trauma to his liver on examination at Royal Alexandria Hospital. Mr Storrie’s presentation, the reported history of his having consumed n-bomb, and the results of investigations undertaken at the hospital supported the diagnosis made by the clinicians that Mr Storrie’s condition resulted from drug toxicity associated with his consumption of n-bomb. Had Mr Storrie not consumed n-bomb he would on the balance of probability not have sustained the trauma to his liver. His consumption of n-bomb prevented his being able to provide an accurate history of injury to medical staff, to enable them to identify the injury to his liver and undertake treatment for this injury. His consumption of n-bomb was a critical factor in his death.
Representation at the Inquiry:
For the Crown: Mr Quither, Procurator Fiscal Depute (“PF”)
For the family of Antony Scott Fisher Storrie: Mr Heaney, Counsel
For the Chief Constable, Police Scotland: Mr McGlone, Solicitor
For PC Richard Haining: Mr Watson, Solicitor Advocate
For PC Douglas McGlynn: Mr Vaughan, Solicitor Advocate
For the Greater Glasgow Health Board: Ms Doherty, Counsel
General Legal Framework
[1] This was an inquiry held under section 1(1)(a)(ii) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, on the ground that the person who died was, at the time of his death, in legal custody.
[2] Fatal accident inquiries and the procedure to be followed in the conduct of such inquiries are governed by the provisions of the 1976 Act and the Fatal Accidents and Sudden Deaths Inquiry Procedure (Scotland) Rules 1977 made under section 7(1) of the Act. The purpose of an inquiry held in terms of the 1976 Act is for the sheriff to make a determination setting out the following circumstances of the death, so far as they have been established to his satisfaction:
(a) where and when the death and any accident resulting in the death took place;
(b) the cause or causes of such death and any accident resulting in the death;
(c) the reasonable precautions, if any, whereby the death and any accident resulting in the death might have been avoided;
(d) the defects, if any, in any system of working which contributed to the death or any accident resulting in the death;
(e) any other facts which are relevant to the circumstances of the death
- all in terms of section 6(1) of the Act.
[3] The Court proceeds on the basis of evidence placed before it by the Procurator Fiscal and by any other party to the inquiry. The determination must be based on the evidence presented at the inquiry and is limited to the matters defined in section 6(1) of the Act. Section 6(3) of the Act sets out that the determination of the sheriff shall not be admissible in evidence or be founded on in any judicial proceedings, of whatever nature, arising out of the death or out of any accident resulting in the death. While this prohibition is intended to encourage a full and open exploration of the circumstances of a death it also reflects the position that a Fatal Accident Inquiry is not a forum designed to establish legal fault.
The Proceedings, Witnesses and Evidence
[4] Preliminary hearings of the inquiry were held on 23 February, 23 March, 20 June, 19 July and 28 July 2016. At the last of these preliminary hearings I refused a motion by Mr Heaney on behalf of the family for recovery of - the Police Investigation and Review Commissioner’s Report; documents held by Crown Office in relation to the death of Mr Storrie; and guidelines memoranda or instructions from Greater Glasgow Health Board setting out the circumstances in which a critical incident review was to be held.
[5] The inquiry heard evidence over a total of seven consecutive days commencing on 16 August 2016. A joint minute was also lodged. Parties provided written submissions and a hearing on submissions took place on 21 September. It was agreed that a number of the witnesses should receive a warning against self-incrimination. All these witnesses however gave unrestricted evidence which assisted the inquiry.
[6] Evidence was led principally by the Procurator Fiscal Depute, in accordance with the duty under section 4(1) of the 1976 Act. Evidence was also led on behalf of the Health Board from Dr Stephen Cole. The Crown witnesses were as follows:
1. Andrew McLaughlin
2. Nicholas Donaldson
3. Bernadette Mary Campbell
4. Christopher Fox
5. Marianna McColgan
6. Donna Bowie
7. Richard Haining
8. Douglas McGlynn
9. William Brandon
10. James Kyle
11. Julie Henry
12. Dr Richard Stevenson
13. Greig Baxter
14. Dr Jamie Adams
15. Dr Charles Allister
16. Dr Kathryn Puxty
17. Prof Nigel Webster
18. Dr Michael Johnston
19. Dr Catriona Wallace
20. Dr Michael Brett
21. Dr Brian Digby
22. Dr Julie McAdam
[7] Parties lodged a joint minute and there was substantial agreement in the submissions as to the findings which I should make. I do not rehearse all the submissions or evidence in detail, although I refer to particular submissions or evidence where appropriate.
What happened
[8] Antony Scott Fisher Storrie (Mr Storrie) was a 25 year old single man. At the time of his death, he lived in Flat 3/1, 1 Townhead Terrace, Paisley with Andrew McLaughlin. He had lived there since about March 2013.
[9] Mr Storrie worked for Amazon, from the flat, dealing with customer issues. On Friday 28 June 2013, Nicholas Donaldson, a friend of both Mr McLaughlin and Mr Storrie attended at the flat. He and Mr McLaughlin started drinking in the early part of the evening, around 5.00pm. They were joined, sometime between 6.00pm and 7.00pm, by Mr Storrie, his having completed his work for Amazon. Later in the evening Christopher Fox and James Caldwell joined them in the flat. During the evening Messrs Donaldson, McLaughlin and Storrie all consumed alcohol, and according to Mr Fox, were taking drugs. During the course of the evening they played on an X-Box and listened to music. In the latter part of the evening Mr Caldwell and Mr Fox returned to Mr Fox’s mother’s flat on the first floor. Mr Storrie had obtained a quantity of n-bomb in tab form through the internet. Tabs are created by a solution of the compound being dripped onto a piece of blotting paper about the size of a pinkie nail. The drugs had been delivered by post to his flat in Townhead Terrace. He, Mr Donaldson and Mr McLaughlin all consumed some tabs of n-bomb. It is unclear how many tabs of n-bomb were consumed by any of the three of them. Mr McLaughlin’s best recollection was that he had consumed two tabs, with the others having consumed more. Mr McLaughlin went to bed in the early hours of Saturday 29 June 2013.
[10] Mr Donaldson was significantly intoxicated as a result of the consumption of alcohol and drugs on the evening of 28 into 29 June. His recollection was poor and his evidence extremely vague as to what occurred. He was unable to give a clear account of what happened after Mr McLaughlin went to bed, save that he and Mr Storrie continued with their consumption of alcohol and drugs and they had taken more n-bomb as they were not getting a big enough hit. Mr Donaldson was candid as were Mr McLaughlin and Ms McColgan about their recreational consumption of drugs. They stated they had been regular users of illicit substances and took these in combination with alcohol. Both Mr Donaldson and Mr McLaughlin recounted having previously consumed n-bomb, but not with Mr Storrie. They understood that Mr Storrie himself had also previously consumed n-bomb. Mr McLaughlin reported that both he and Mr Storrie had used the internet to gather information about n-bomb. Mr Donaldson, Mr McLaughlin and Mr Storrie were aware that there were risks associated with their use of drugs, and binging on drugs and alcohol.
[11] N-bomb was described at various stages in the inquiry as a “legal high”, but was in fact the subject of a temporary prohibition order issued on 10 June 2013, Misuse of Drugs Act 1971 (Temporary Class Drug) Order 2013 (SI2013/1294) and was classified as a controlled drug on 10 June 2014 by virtue of The Misuse of Drugs Act 1971 (Ketamine etc.)(Amendment) Order 2014 (SI2014/1106).
[12] Dr Stevenson, a consultant in emergency medicine at Glasgow Royal Infirmary with a particular interest in forensic matters and toxicology, and who provides direct input to Frank (a not for profit website designed to educate on the dangers of drugs), and PC Greig Baxter of the Police Scotland Statement of Opinion Unit provided more information on n-bomb. They explained that they had begun to have some visibility of n-bomb on websites in early 2013. N-bomb was identified as having similar properties to LSD and would produce a hallucinogenic effect. N-bomb was recognised as being an extremely potent solution. Dr Stevenson explained that the compound acted on a particular brain receptor responsible for recognition of surroundings and impacted on how a user would interpret signs, colours, smells and people’s behaviour. He explained that no information was available as to a safe dose of n-bomb and that the usual method of delivery was in tab form. He believed the creation of tabs by a solution of the compound being dripped onto blotting paper made regulation of dose problematic. The physical effects of the drug were thought to last longer than LSD and he was aware of evidence of cognitive disturbance some twenty four hours after consumption. Reports of users’ behaviour were that they were often unable to communicate and Dr Stevenson concluded that a user would be unlikely to feel pain when intoxicated. The physiological effects of n-bomb include an increase in heart rate, temperature and blood pressure although the literature also recognised instances of blood pressure being lowered. A number of fatalities arising from the consumption of n-bomb have been recorded.
[13] Mr McLaughlin reported waking up on the Saturday 29 June, to find Mr Donaldson asleep in the living room and encouraged him to go into his bed. He believed around 4.00pm he made some food for himself, and offered some to Mr Storrie, who he described as being basically asleep in his bed. He left food on the bedside table, by Mr Storrie’s bed. At approximately 8.00pm, Mr McLaughlin was sitting in the living room when Mr Storrie entered in an intoxicated and agitated state. He jumped onto the glass coffee table, causing various glasses to be knocked off and break. He fell off, landing heavily on the sofa, knocking it over. Mr McLaughlin sought to calm Mr Storrie down, and went to obtain the hoover from the kitchen. As he did so he heard further crashing, and returned to help Mr Storrie get up. Mr Storrie was, at this point, not speaking clearly and merely mumbling incoherently. Mr McLaughlin was concerned at the damage Mr Storrie was doing to the living room and escorted him back to his bedroom, where he shut the door. He then heard loud crashing and banging noises coming from the bedroom, and was very concerned for Mr Storrie. He initially phoned his girlfriend, Marianna McColgan and thereafter phoned the emergency services. Calls were recorded at 9.08pm 9.10pm and 9.17pm. The audio recordings of these calls have background noise which is consistent with Mr Storrie causing a disturbance. Mr McLaughlin explained that his flatmate had taken legal highs and was smashing up the flat. He believed that the police would be better equipped to control Mr Storrie in a secure and safe environment until he sobered up.
[14] The report of the first call was conveyed to Constables Haining and McGlynn who had just commenced nightshift and were still in the muster room at Mill Street police office in Paisley. The second call was received before they left the muster room and they thereafter proceeded to Townhead Terrace in response to the call. The CCTV video recording from Townhead Terrace shows their police car arriving at 9.22pm. The constables heard no sounds of a disturbance as they proceeded up the stairs to the third floor flat. Mr McLaughlin was waiting for them at the door of the flat. He told them that Mr Storrie had consumed n-bomb and alcohol. Mr Storrie was in a distressed state, smashing up the flat and he had confined Mr Storrie in his bedroom.
[15] The police proceeded to the bedroom. PC McGlynn entered the room in front of PC Haining and they saw Mr Storrie sitting with his knees up towards his chest in the middle of the room facing the open window. Items of furniture including a bedside table and computer monitor were strewn across the floor. PC McGlynn moved the bedside table onto the bed to clear space as he moved towards Mr Storrie. As PC McGlynn approached Mr Storrie he sought to explain to him that they were police officers and they were there to help him. There being no immediate response from Mr Storrie, he repeated this explanation. At this point Mr Storrie stood up, and as he stood up, he swung a punch at PC McGlynn, which PC McGlynn managed to parry. Thereafter the officers sought to restrain Mr Storrie, and PC McGlynn advised him he was under arrest. Mr Storrie struggled and the officers pushed him down onto a chair where PC McGlynn succeeded in handcuffing his left wrist and PC Haining his right. Despite the handcuffs having been applied Mr Storrie continued to struggle. Given his agitated reaction the officers manoeuvred Mr Storrie onto the floor, where they secured his legs with fast straps. Fast straps are a limb restraint system, they are 150cm velcro straps which are easily applied, and form part of police officer personal protective equipment. PC Haining and PC McGlynn only used such force as was reasonable and they acted in accordance with their training and recognised procedure in approaching and subsequently restraining Mr Storrie.
[16] PC McGlynn characterised Mr Storrie’s behaviour as displaying signs of “excited delirium”. PC Haining and PC McGlynn assessed that Mr Storrie was significantly unwell and was in need of urgent medical assistance and determined that the most appropriate course was for them to carry him downstairs to the police vehicle and convey him directly to the Royal Alexandra Hospital for medical input, notwithstanding that he had been arrested. Before leaving the flat PC Haining took from the bedroom a pair of trainers and jeans for Mr Storrie, who was only wearing a tee shirt and boxer shorts. The jeans and trainers were thrown down to the foot of the common stair to allow both officers to carry Mr Storrie down the stairs. The action of the officers to convey him directly to the hospital gave Mr Storrie the best possible chance of survival. The officers told Mr McLaughlin as they left the flat with Mr Storrie that they were taking him to hospital. The police officers took reasonable care in carrying Mr Storrie down the stairs and took a number of short breaks in doing so. The CCTV video showed the police car leaving Townhead Terrace at 9.36pm, 14 minutes after its arrival.
[17] The video at the Royal Alexandria Hospital A&E showed PC McGlynn taking out a wheelchair. The officers determined it would assist them, given that Mr Storrie’s legs were fast strapped, in transporting him into A&E. This proved problematic as Mr Storrie’s feet were dragging as the stirrups of the wheel chair could not be used because of the fast straps. The video showed them dragging him for the short distance from the double doors at the entrance to A&E towards a trolley at which point the recording showed Mr Storrie collapsing to the ground. He was described as having a seizure. Constable Haining placed him in the recovery position and Constable McGlynn summoned medical assistance. Within a matter of seconds a number of medical staff attended and the police officers assisted the medical staff in lifting Mr Storrie onto a trolley. He was initially taken to an A&E cubicle, for assessment and within minutes transferred to the resuscitation area. During this period he was still struggling and lashing out and the fast straps and handcuffs were left on.
[18] Mr Storrie was initially seen and assessed by Dr Jamie Adams a junior doctor in A&E. In the resuscitation room responsibility for his care was taken over by the A&E consultant on duty, Dr Charles Allister, and by Dr Kathryn Puxty, a specialist registrar in intensive care medicine, both of whom were already in the resuscitation room. Dr Allister spoke to his note in the medical records of the history provided and his initial findings on examination. It was accepted this note was mistimed at 9.15. The note records “25 year old brought in by police because he had taken “legal high” and had wrecked the flat. Very combative and aggressive. Brought restrained. On admission Glasgow coma scale 5, incomprehensible, no eye opening, just moving limbs. Hypotensive blood pressure 60/35 tachycardia 150+ No saturation recordable Peripheral shut down. Cold but core temperature 38. Pupils dilated but barely reactive, AE (air entry) all areas. Abdomen soft. Initial treatment was with help from ICU staff to provide IV access, an arterial line and rapid sequence intubation. Initial venous gas results were lactate greater than 20 and H+ of 154. Dr Allister concluded, following his examination of Mr Storrie, that he was probably suffering from serotonin syndrome as a result of the drugs which he had taken. He confirmed that on examination Mr Storrie’s abdomen was soft and there were no signs of trauma consistent with the findings at post mortem.
[19] The medical staff were all of the view that Mr Storrie was critically ill and at imminent risk of death. Dr Puxty followed the well-recognised ABC protocol of checking airway, breathing and circulation. She decided to undertake rapid sequence induction, thereby intubating Mr Storrie to minimise the risk of death resulting from airway obstruction. Dr Wallace, a junior member of the ICU team, put in a central line and an X-ray was taken to confirm its correct position. This X-ray did not identify the broken ribs found at post mortem. Aggressive cardio vascular resuscitation was undertaken with Mr Storrie being given large volumes of intravenous crystalloid fluid and vasoactive drugs - adrenaline and noradrenaline. Once Mr Storrie was sedated the handcuffs and fast straps were removed. This was done as soon as it should have been. Both Dr Puxty and Dr Allister recalled ligature marks on Mr Storrie’s wrists and ankles consistent with his having been restrained. The initial aggressive treatment proved effective as Mr Storrie’s condition partially stabilised and haemodynamic stability was achieved. The presentation and the history available suggested that Mr Storrie was in multi-organ failure as a result of drug ingestion. After intubating Mr Storrie, Dr Puxty called Dr Brett, the intensive care consultant, who arrived at approximately 10.30. Dr Brett approved of the lifesaving management already put in place by the team, when he arrived. His examination of Mr Storrie did not reveal any external sign of major abdominal injury and without any history of trauma he agreed with the working diagnosis of Mr Storrie’s condition being caused by drug toxicity. He identified following his examination of Mr Storrie that his condition was life threatening. He had very low blood pressure, very high heart rate and his metabolic parameters and arterial blood gasses were very poor. Dr Brett believed Mr Storrie was going into multiple organ failure and was unlikely to survive. Dr Brett advised the police officers that he was concerned that Mr Storrie would not survive. This resulted in the police taking action in anticipation of a death in custody.
[20] The initial treatment of Mr Storrie took more than an hour and thereafter intensive therapy continued to seek to keep Mr Storrie alive and to seek to establish more about what was wrong with him, around 1.00am on Sunday 30 June, Mr Storrie was transferred to ICU.
[21] By this time Dr Puxty had spoken to Mr Storrie’s mother and grandfather, explained to them Mr Storrie was gravely ill and might not survive. Dr Puxty also printed out the national poisons unit database Toxbase information on n-bomb and telephoned the National Poisons Unit for further advice on treatment for n-bomb toxicity. Dr Wallace spoke to the completion of the intensive care admission form at page 17-19 of the notes. Her notation “SNT” reflected that on examination Mr Storrie’s abdomen was soft, non-tender. Dr Wallace continued to observe Mr Storrie until she was off duty at about 8.30am the next morning. Dr Puxty also completed a more substantive entry in the notes for Mr Storrie, recorded at pages 22-24 of the hospital records which was consistent with what Dr Allister had recorded and this followed a discussion of issues and plans with Dr Brett. In this note she records the findings of an echocardiogram which she performed on Mr Storrie “– hyper dynamic LV – looks under filled - swing on arterial line +++” She identified that heart function was also prejudiced by the severely acidic state of Mr Storrie’s blood. Dr Puxty reviewed Mr Storrie following his transfer to ICU, and in her entry timed at 1.30am on Sunday 30 June 2013 recorded Mr Storrie’s problems as ”1 CVS collapse 2 Metabolic acidosis 3 lowered GSC 4 AKI 5 raised temperature 6 Transaminases.” She believed that her clinical findings were in keeping with a severe adverse toxic reaction to the consumption of a legal high. She was concerned that Mr Storrie would not survive because of his organ failure as a result of his drug ingestion. Dr Puxty did not find any injury to Mr Storrie’s abdomen. Her notes record that his abdomen was soft. No external injuries were identified by the medical staff at the Royal Alexandria Hospital, or in the post mortem, which would have been consistent with the liver injury. The clinicians did not consider there to be any basis to undertake a F.A.S.T. scan (Focused Assessment with Sonography in Trauma) as there were no history of abdominal injury. Neither did they consider sending Mr Storrie for a C.T. scan and in any event would have been reluctant to do so given Mr Storrie’s critical condition and the risk associated with transferring him for a scan.
[22] Dr Brett and Dr Puxty remained in the hospital until sometime after 2.30pm. Dr Wallace remained in the hospital until the end of her shift on the Sunday morning. Responsibility for the care of Mr Storrie was taken over by Dr Brian Digby the duty ICU consultant on the morning of Sunday 30 June 2013. He had a telephone handover with Dr Brett at approximately 8.30am and one of the middle grade staff in ICU team, who came on duty on the Sunday morning, Dr Lafferty examined Mr Storrie at 9.30am. Dr Digby examined Mr Storrie again around noon. His note of this examination is at page 16 of the hospital notes. This records his examination revealed nothing to suggest any internal injury and was consistent with a diagnosis of serotonin syndrome. Dr Digby’s conclusion following that examination conformed to Dr Brett’s earlier assessment that Mr Storrie was unlikely to survive. Dr Digby found nothing to suggest a need for a F.A.S.T. scan nor did he consider there was a basis to undertake a C.T. scan. He arranged to speak to Mr Storrie’s next of kin and advised Mr Storrie’s mother that Mr Storrie’s condition had deteriorated further and he was not responding to treatment. This resulted in the decision that Mr Storrie should not be resuscitated. Dr Digby completed a Critical Care End of Life Pathway Assessment. By 2.40pm there had been further deterioration in Mr Storrie’s condition, shortly thereafter Dr Digby authorised the withdrawal of adrenaline and noradrenaline. He did so anticipating that these drugs having been stopped Mr Storrie would pass away quickly. Dr Digby pronounced Mr Storrie dead at 3.50pm on Sunday 30 June 2013.
[23] The APACHE II (Acute Physiological and Chronic Health Evaluation) score calculated for Mr Storrie on the basis of the assessment and diagnosis by the doctors at the Royal Alexandria Hospital treating Mr Storrie was 36 which carried an 85% percent chance of mortality. Adjusted for haemorrhagic shock this increased to a 90% chance of mortality. As explained to the inquiry this score is used to indicate the severity of illness and to help predict outcome primarily for audit purposes. It is not intended to be applied to individual patients. It does however reflect the life threatening nature of Mr Storrie’s condition on admission.
[24] The post mortem identified the cause of death as Intra-abdominal haemorrhage, due to liver laceration, due to blunt force trauma. It identified that Mr Storrie had sustained 4 broken ribs and a significant liver laceration. The laceration to the liver would have required a significant decree of force. Typically such an injury would be associated with a road traffic accident, a fall from a height, a rapid deceleration injury, serious assault or a kick from a horse. There was no evidence to account for these injuries. There was no evidence that Mr Storrie had been assaulted or had sustained these injuries prior to awaking on the evening of 29 June 2013. Mr Storrie’s liver and rib injuries were most likely to have been caused when he injured himself while in an agitated state within the flat between 8.00pm and 9.20pm.
[25] The outcome of the post mortem was a major surprise to all those who had been involved with Mr Storrie’s care. There was nothing which they identified on examination or of which they were made aware which suggested he had sustained such a significant trauma as to have caused such an injury. Following the post mortem Drs Allister, Brett and Digby discussed the matter with colleagues. Mr Storrie’s presentation and the treatment administered was further discussed by them in the context of a morbidity and mortality review. The outcome of this review was support for the treatments administered and agreement that there was no reason, given how Mr Storrie had presented, to suspect major abdominal injury.
[26] The chronology of Crown Investigation, produced by the Crown on a voluntary basis, following the motion on the specification on behalf of Mrs Myra Storrie demonstrated the active and comprehensive investigation which had been undertaken into Mr Storrie’s death.
Observations on the evidence
[27] Much of the evidence was not in dispute, but I should mention two aspects where there was a conflict of evidence. In so far as there was a conflict between the evidence of the police officers and Mr McLaughlin and Mr Donaldson as to the actions taken by PC Haining and PC McGlynn in the flat, I preferred the account given by the two police officers. I found their accounts to be credible and reliable. Mr Donaldson was extremely vague and was still significantly under the influence of the drugs and alcohol following his having been roused after 9.00pm by Mr McLaughlin. Mr McLaughlin, whom I accept was trying to give his evidence in an accurate manner, was himself agitated. I do not view the conflict as being of particular import in relation to where Mr Storrie was in the bedroom, or whether the police officers had told Mr McLaughlin they were taking Mr Storrie directly to the Royal Alexandria Hospital. There was nothing to suggest any more likelihood of Mr Storrie having sustained more significant trauma, such as to give rise to the liver and rib injuries in the course of being restrained on the bed as opposed to being restrained in the manner described by the police officers, such as might have cast doubt on their account. I therefore accepted the account of the police officers that they had restrained Mr Storrie first on the chair which was located at the end of the bed and then on the floor. While the language said to have been used by the officers towards Mr Donaldson might have given rise to a question about the propriety of their behaviour I placed more weight on the evidence of Ms Bowie who saw the police officers put Mr Storrie into the back of the police car. She described the officers as being calm and said that she had no concerns about how they were dealing with the man and did not think they were being rough with him. Her evidence also corroborated the officers’ evidence about how they manoeuvred Mr Storrie into the back of the police car. Ms Bowie’s evidence together with the action of the police officers in taking clothing for Mr Storrie supported the impression that I formed of their acting professionally.
[28] The medical evidence was clear that considerable force would have been required to cause the damage to Mr Storrie’s liver as found by the post mortem. PC Haining and PC McGlynn and Mr McLaughlin denied striking Mr Storrie in any way consistent with the injuries which the post mortem found him to have sustained. Mr Donaldson confirmed there was no disagreement between him and Mr Storrie. There was no evidence to support any individual having struck Mr Storrie with such force as required to break his four ribs and to lacerate his liver. I accepted that the officers did not drop Mr Storrie in the course of their carrying him down the stairs of the flat to the police car or in carrying him between the entrance to the common close at Townhead Terrace to the police car or in taking him from the police car into the accident and emergency department of the Royal Alexandria Hospital, such as to have caused Mr Storrie’s rib and liver injuries.
[29] There was no evidence of Mr Storrie having sustained an injury prior to the evening of Saturday 29 June 2013. Accordingly on the balance of probabilities I concluded that Mr Storrie accidently injured himself within the flat while in an agitated state between approximately 8.00pm and 9.20pm.
[30] Dr Stevenson was of the view that Mr Storrie’s vital signs on admission were suggestive of life threatening organ failure. He confirmed these represented a classic presentation of severe drug intoxication which he would have treated as generic substance poisoning. He accepted a sensible working diagnosis was intoxication with n-bomb. He supported the involvement of ICU specialists and commented on the difficulties of gathering information on what has been consumed as often a number of substances have been taken together. That view was also supported by Dr Cole, Consultant in Anaesthesia and Intensive Care Medicine, Ninewells Hospital and Medical School, and Dr Johnstone, Consultant in Emergency Medicine, Ninewells Hospital Dundee, in their reports and evidence and by Dr Nichol, Consultant in Accident and Emergency Medicine, Ninewells Hospital Dundee and Perth Royal Infirmary, in his report. These experts all accepted the doctors at Royal Alexandria Hospital had acted reasonably in proceeding as they did. In their view there was no reason to suspect a liver injury given the absence of history of trauma and there being no visible signs of trauma.
[31] Professor Webster who is Professor of Anaesthesia and Intensive Care Medicine based at Aberdeen Royal Infirmary spoke to a report which he had produced at the request of the Crown and was dated 21 October 2014. He was only the dissenting voice; he expressed a view that some signs should have resulted in further investigation being undertaken. He believed that certainly after Dr Digby took over as the on-call consultant in charge of ICU, reconsideration should have taken place in respect of the diagnosis which may have alerted medical staff to the extent of blood loss. I accepted Dr Digby’s evidence that he had examined Mr Storrie and, reasonably, remained of the same view as his colleagues that Mr Storrie’s condition arose from his drug overdose.
[32] In Professor Webster’s opinion the echocardiogram results were indicative of an underfilled heart which would be a marker for blood loss. He suggested that the low CVP low blood pressure continued tachycardia with an underfilled but well contracting heart in the face of extensive fluid replacement and vasopressor support should have alerted those treating Mr Storrie to hypovolemic shock, i.e. shock occasioned by a blood loss. He also considered that the low haemoglobin on admission should have alerted the team to other possible reasons for cardiovascular collapse.
[33] In Professor Webster’s view there were two further actions which might have been taken by the medical staff. Firstly that a F.A.S.T. scan might have been undertaken in A&E. Such a scan, which can be undertaken at the bedside, is used to assist clinicians to assess the abdomen of patients. Secondly, he also considered that a C.T. scan may also have been appropriate.
[34] Dr Johnstone, in disagreeing with Professor Webster’s view, was clear that without any history or external signs of trauma he would not have expected the medical staff at the Royal Alexandria Hospital to have undertaken a F.A.S.T. scan. Dr Puxty, who of course had to take clinical decisions on Saturday 29 June 2013, rejected the suggestion that there was a basis to look further given the history and findings on examination and I accepted her interpretation of the echocardiogram as also being consistent with the diagnosis of drug overdose and associated multiple organ shutdown.
[35] Dr Johnstone was also of the view Mr Storrie’s hypovolemic shock could be attributed to other factors beyond simply blood loss, namely excessive loss of fluid, and he particularly evidenced sweating as a possibility. He also disagreed with Professor Webster’s view in relation to the impact of n-bomb and noted that Toxbase reported both hypertension and hypotension as being associated with n-bomb consumption. In his opinion hypotension was likely to occur as the drug over-rode the body’s natural systems, and the resultant acidosis occasioned organ failure and shutdown. All of which he accepted as being consistent with the working diagnosis of organ failure secondary to severe metabolic acidosis secondary to toxicity resulting from ingestion of n-bomb.
[36] I preferred the views of the experts apart from Professor Webster that there was no criticism to made because a F.A.S.T. scan was not undertaken. The T for trauma in the acronym emphasises that this is a tool in trauma cases. There being no history of trauma or sign of trauma on examination I accepted there was no indication for such an investigation. I also preferred the view of the other experts that given Mr Storrie’s critical condition he should not have been sent from ICU for a C.T. scan. Professor Webster’s evidence was in part undermined by his assertion that all the literature he had read about n-bomb suggested that it would have the effect of increasing not lowering blood pressure. This conflicted with the information from Toxbase and from the national poisons service from which the doctors had taken advice in relation to Mr Storrie. The Toxbase data sheet reported that hypotension was also associated with n-bomb consumption. The current guidance issued on Toxbase confirmed this position. I also reached the view that Professor Webster’s opinion was influenced by the post mortem result which caused him to consider the results and identify factors which might have been consistent with the liver injury with the benefit of hindsight, but were not reasonably apparent to the medical staff treating Mr Storrie based on examination findings and history.
Observations on Findings
[37] The time and place of death were agreed in the joint minute and accordingly are uncontroversial.
[38] In relation to the cause of death, while I accepted Dr McAdam the pathologist’s evidence on the cause of death, I concluded it was appropriate to also make reference to the consumption of n-bomb. The procurator fiscal and counsel for Mr Storrie’s mother both identified that had Mr Storrie not ingested n-bomb his life would most likely not have been lost. I accepted and agreed with their submissions.
[39] In relation to the injuries Mr Storrie sustained to his ribs and liver, there was no evidence before the inquiry to support his having been assaulted. Neither was there any evidence to suggest Mr Storrie had sustained his liver injury before the evening of 29 June 2013. There was no evidence from any witness of Mr Storrie having been struck with such force as may have caused his liver injury between his leaving the flat and his admission to hospital. There was no evidence to suggest he sustained the injury while a patient in hospital. There was evidence of Mr Storrie crashing about the flat at 1 Townhead Terrace between about 8.00pm and 9.20pm when the police arrived following the 999 calls from Mr McLaughlin. The photographs of Mr Storrie’s bedroom show various items such as a bedside table, bedpost and a PC cabinet against which Mr Storrie could have fallen and resulted in the injury to his ribs and liver. For these reasons I was satisfied, on the balance of probabilities, that Mr Storrie’s liver and rib injuries were most likely to have been caused when he injured himself while in an agitated state within the flat at Townhead Terrace. The n-bomb caused Mr Storrie to be in the agitated state. The effects of the n-bomb then prevented him from being able being able to give any explanation of the injury which he had sustained. While as Dr McAdam said the drugs were not a pathological cause of death, nonetheless Mr Storrie’s death would in all probability not have occurred had he not taken n-bomb.
[40] No party to the inquiry invited me to make a finding in terms of 6(1)(d) and I made no finding under that subsection. I accept there was prompt attendance by the police in response to the emergency call, that the officers acted professionally and expeditiously in dealing with Mr Storrie and correctly made the decision to take him directly to hospital. I endorse what was submitted by counsel for Mr Storrie’s mother, and commend the actions of the two police constables whose prompt action in conveying Mr Storrie directly to the Royal Alexandria Hospital gave him the best possible chance of survival. I also accept that the medical staff at the Royal Alexandra Hospital acted in a professional and appropriate manner. The diagnosis which they made was entirely reasonable given the presentation of Mr Storrie, the history provided and in particular, the absence of any history of trauma. Rather than make any criticism of their care, I would commend their efforts to endeavour to save the life of Mr Storrie. I am satisfied that the doctors involved in Mr Storrie’s care did all that they reasonably could have done to assist Mr Storrie.
[41] I accepted the submission of counsel for Mr Storrie’s mother that it was appropriate to make a finding under 6(1)(e) which reinforces the tragic fact that Mr Storrie’s death resulted as a consequence of his voluntary consumption of n-bomb.
[42] I make no recommendations. I do however offer the following comments. Mr Storrie’s death is a stark reminder of the risks posed by drug taking. It is clear from the evidence presented to this inquiry that n-bomb is a potent compound producing significant hallucinogenic effects. It is also apparent from the evidence given by experienced consultants in emergency medicine of the significant risks posed to those taking cocktails of drugs in uncertain dosages and of uncertain chemical composition or purity. Risks are exacerbated where, as in Mr Storrie’s case, an individual’s consumption of drugs prevents them from giving a history of what they have consumed or what has happened to them. It is to be hoped that anyone who hears of the outcome of this inquiry may reflect on that and reflect on whether they should take the risk of consuming drugs, which may so affect their behaviour and ability to communicate as to result in their serious injury or, like Mr Storrie, their death.
[43] I would commend all parties for the efficiency and courtesy with which they conducted the inquiry. Finally, I should like to extend my sympathy to Mr Storrie’s family and in particular to his mother Myra Storrie. She was present throughout the inquiry, and conducted herself with considerable dignity in what must have been most distressing circumstances. I extend my sincere condolences to Mr Storrie’s family and friends for their loss.