2014FAI23

SHERIFFDOM GLASGOW AND STRATHKELVIN AT GLASGOW

GLASGOW, 04 August 2014.  The Sheriff, having considered all the evidence adduced, DETERMINES:

(1)          In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 that MARTIN NEIL HILL, born 11 September 1965, who formerly resided at 35 Lowergate, Clitheroe, Lancashire died at a time not precisely established between 18.10 hours and 19.00 hours on Friday 27 September 2013 whilst detained in legal custody as an untried prisoner within cell number 3/50, C Hall, HM Prison Barlinnie, Glasgow.  Mr Hill was the sole occupant of this cell.  He was pronounced dead on Friday 27 September 2013 at 19.00 hours. 

(2)          In terms of section 6(1)(b) of the Act that the cause of Mr Hill’s death was intra-abdominal haemorrhage due to a ruptured pancreatic pseudocyst with splenic vein fistula.  Ischemic heart disease was a contributory cause of Mr Hill’s death.

NOTE:

[1]          This Fatal Accident Inquiry was held in terms of section 1(1)(a)(ii) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 into the circumstances of the death of Martin Neil Hill, who was pronounced dead at 19.00 hours on Friday 27 September 2013 within Cell 3/50, C Hall, HM Prison Barlinnie, Glasgow. 

[2]          The procurator fiscal was represented by Mr Quither, Procurator Fiscal Depute.  Miss Phillips, Solicitor, appeared for Scottish Ministers on behalf of the Scottish Prison Service.  There was no other representation at this Inquiry. 

[3]          The parties were able to agree all the evidence which was encompassed in a joint minute of agreement.  I am indebted to Mr Quither and Miss Phillips for the considerable work which they undertook to agree the undisputed evidence in this Inquiry.  No evidence was led before this Inquiry. 

[4]          In his closing submission, the procurator fiscal depute stated that contact had been made with the deceased’s relatives.  He confirmed that the family had no issues concerning the circumstances or cause of Mr Hill’s death.  In his closing submission, the procurator fiscal depute sought only formal findings in terms of section 6(1)(a) and (b) of the 1976 Act.  He sought no findings in terms of paragraphs (c), (d) or (e).  The procurator fiscal depute’s submissions were adopted in full by Miss Phillips.

[5]          As appears from the joint minute, Mr Hill appeared at Glasgow Sheriff Court on 23 September 2013 on petition charged with two serious statutory offences.  Bail was refused.  Mr Hill remained in custody from 23 September 2013 until his death on 27 September 2013.  Throughout this period he was in legal custody as an untried prisoner within HM Prison Barlinnie, Glasgow.  At the time of his death he had been allocated to cell C3/50 in C Hall.  He was the sole occupant of this cell. 

[6]          As appears from the joint minute, there had been concern regarding whether Mr Hill might be a suicide risk.  Initially, when he was received at HM Prison Barlinnie, he was assessed and made subject to an immediate care plan to safeguard his welfare.  He was subject to observation every 15 minutes.  On 24 September 2013, following a case conference, he was assessed as posing no apparent risk of suicide and the observation requirement was removed.  Thereafter, Mr Hill’s physical and mental health was monitored on a regular basis, all as recorded in the Scottish Prison Service’s Discharge Summary Report.  During the period from his admission until about 18.10 hours on 27 September 2013 there is no record of any complaint being made by Mr Hill regarding his physical health or any indication of any issue regarding his physical health becoming apparent. 

[7]          On 27 September 2013, Mr Hill collected his evening meal at about 17.20 hours from the lower flat of C Hall.  He returned to his cell.  At about 18.10 hours Prison Officer Stephen Chopping was working in the course of his employment and engaged collecting plates from the cells after the prisoners’ evening meal.  When Mr Chopping attended at cell C3/50 on Level 3 of C Hall, which was occupied solely by Mr Hill, Mr Chopping found Mr Hill lying on the floor.  It seemed to Mr Chopping that Mr Hill was having a fit of some sort in that he was convulsing and appeared to have urinated.

[8]          Mr Chopping called for medical assistance and, in the meantime, he and a colleague entered the cell.  A towel was placed beneath Mr Hill’s head in an effort to alleviate his discomfort.  When Nurse Stewart Curtis attended, Mr Hill appeared to recover but complained of stomach pains and of having soiled himself.  Mr Hill attributed this to the evening meal he had eaten earlier.  Mr Hill was asked and encouraged to sit on his bed or a chair but he advised that he was more comfortable on the floor.  Mr Hill had not made earlier complaint of stomach pains to Mr Chopping or so far as Mr Chopping was aware to anyone else.

[9]          After a short attendance with Mr Hill, Nurse Curtis returned to the Nurses’ Station in the lower flat of C Hall to check Mr Hill’s medical history.  Mr Chopping remained with Mr Hill.  Shortly after Mr Curtis left, Mr Hill became quiet and his breathing became more laboured.  Mr Chopping requested Mr Curtis to return as a matter of urgency.  Mr Curtis returned and upon his return found Mr Hill to be unresponsive and not moving.  Mr Hill was still on the floor in the cell.  Mr Curtis examined Mr Hill and found him to have no pulse or heartbeat.  Assisted by two nursing colleagues, he commenced cardio-pulmonary resuscitation but there was no response.  Attempts to resuscitate Mr Hill by the use of a defibrillator device continued for between 15 and 20 minutes until the arrival of Scottish Ambulance Service paramedics to whom the care of Mr Hill was relinquished. 

[10]        The paramedics took over attempts to resuscitate Mr Hill shortly after 18.30 hours.  They continued these efforts for about 20 minutes and then, in accordance with their standing operating protocols, stopped efforts.  Paramedic Fiona Hendry pronounced Mr Hill’s life extinct at 19.00 hours, witnessed by her colleague Philip McAleer. 

[11]        At about 19.30 hours Police Constable James MacDonald received a call to attend at HM Prison Barlinnie regarding Mr Hill’s death.  Accompanied by Police Constables Alison Miller and Police Sergeants Malcolm MacKay and Andrew Nixon he attended with haste.  Upon arrival, he was directed to cell C3/50.  He noted that Mr Hill was lying on the floor, bare chested.  Mr Hill had a piece of cotton wool on his left arm where ambulance staff had provided medical treatment.  These police officers assessed the whole circumstances and made a search of the cell.  They concluded that Mr Hill’s death was not suspicious.  Detective Constables Craig Brogan and James Mitchell attended at the cell at about 21.00 hours and, having considered the circumstances and appearance of the cell and Mr Hill, concurred with this view.  Constable McDonald arranged for witness statements to be taken and at about 21.30 hours confirmed with the attending Police Casualty Surgeon, Dr Andrew McCall, that nothing appeared to him to be suspicious about Mr Hill’s death.  Constable MacDonald was present when undertakers and police photographers attended.  He then went to Shettleston Police Office to complete necessary documentation arising out of this fatality.

[12]        On 3 October 2013 at the Southern General Hospital, Glasgow a post-mortem examination was carried out on the body of Mr Hill by Dr John Williams, Forensic Pathologist.  The cause of death was found to be:

1a:         Intra-abdominal Haemorrhage due to

1b:         Ruptured pancreatic pseudocyst with splenic vein fistula

2:           Ischaemic heart disease.

[13]        Dr Williams reported his findings and opinion, as follows:

“Evidence of significant natural disease in the form of a large pancreatic pseudocyst.  Pancreatic pseudocysts can arise as a complication of acute and/or chronic pancreatitis, a cause of which is alcohol abuse; the background pancreas showed evidence of chronic pancreatitis.  There was evidence of an abnormal connection (ie. a fistula) between this cyst and the splenic vein, and a defect (ie. a hole) in the upper cyst wall.  It is most likely that the cyst had eroded into the adjacent splenic vein as a result of local inflammation, with resulting rapid haemorrhage into the cyst cavity, which in turn has caused the cyst to rupture (due to pressure effects).  This would have led to rapid and significant bleeding into the abdominal cavity causing collapse and cardiac arrest.  Although rare, this form of complication is recognised in the medical literature.”

He further reported:

“There was a further natural disease in the cardiovascular system in the form of severe atheromatous narrowing (ie. furring) of two coronary arteries which may have potentially contributed to this death, through reducing the heart’s physiological reserve to adapt with a large volume of blood loss”.

[14]        Samples of blood were retained for analysis and screening, and indicated very low levels of alcohol which were consistent with post-mortem decomposition and phenazepam, neither of which caused, or significantly contributed to, the death of the deceased.  All other analyses for alcohol and drugs were negative.  Furthermore, neuropathological examination of the deceased’s brain found no significant abnormality.  Post-Mortem Report dated 6 December (pages 5-9), Toxicology Report dated 30 October (pages 12/13) and Neuropathology Report dated 25 November (pages 15/16), all 2013 form Crown Productions 3, 4 and 5 respectively.

[15]        At about 21.30 hours on 27 September 2013 Shona McDonald, Senior Examiner, took photographs within Cell 3/50, C Hall, HM Prison, Barlinnie.  These form Crown production number 1.

[16]        The joint minute records that it is agreed that Mr Hill’s death was not suspicious. The haemorrhage of the cyst into the cavity and subsequent rapture, having been sudden and unexpected, could not have been foreseen or treated.  Mr Hill could not have survived what happened. 

[17]        On the admitted evidence before me I am satisfied that there are no suspicious circumstances surrounding the circumstances of Mr Hill’s death.  The unchallenged findings of the forensic pathologist are clear.  The post-mortem examination of Mr Hill’s body reveals significant evidence of natural disease in the form of a large pancreatic pseudocyst and the pancreas showed evidence of chronic pancreatitis.  There was evidence of a fistula between the cyst and the splenic vein and a hole in the upper cyst wall.  The available evidence all points in the same direction.  Although the form of complication which the pathologist considered had occurred was rare, it is recognised in the medical literature.  This could not have been foreseen or treated and Mr Hill could not have survived the haemorrhage.

[18]        There are no other facts which are relevant to the circumstances of Mr Hill’s death.  Accordingly, only formal findings are appropriate.  I extend my condolences to Mr Hill’s relatives.  The procurator fiscal depute advised that they are content to know that Mr Hill is now at peace.