INQUIRY UNDER THE FATAL ACCIDENTS AND INQUIRIES (SCOTLAND) ACT 1976 INTO THE SUDDEN DEATH OF ROBERT TAIT
Case Reference No. 2B 352/15
SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH
2015FAI15
Inquiry held under the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976 Section 1(1) (a)
DETERMINATION BY Frank Richard Crowe, Esquire, Sheriff of Lothian and Borders at Edinburgh
In inquiry into the circumstances of the death of ROBERT TAIT (date of birth 8 August 1948) and late of HMP Saughton, Edinburgh
EDINBURGH 19 May 2015
The Sheriff determines as follows
[1] In terms of section 6(1)(a) of the said 1976 Act that Robert Tait who was born on 8 August 1948 and late of Her Majesty’s Prison Saughton Edinburgh died at 11 10 am on 30 November 2013 at the Royal Infirmary Edinburgh, while a serving prisoner.
[2] In terms of section 6(1)(b) of the said Act that the cause of his death was
1a Clinically diagnosed multi-organ failure
1b Complications of cellulitis of the lower limbs
[3] In terms of section 6(1)(c) of the Act there were no reasonable precautions whereby the death and any accident resulting in the death might have been avoided.
[4] In terms of section 6(1)(d) of the Act there were no defects in any system of working which contributed to the death or any accident resulting in the death.
[5] In terms of section 6(1)(e) of the Act there are no other facts relevant to the circumstances of the death.
NOTE
Introduction
[1] This inquiry relates to the tragic death of a 65 year old prisoner who died when in custody on 30 November 2013. The inquiry took place at Edinburgh Sheriff Court on 29 April 2015 following upon application to hold the inquiry by the Crown on 5 March 2015. Parties were cited and advertisements appeared in the “Edinburgh Evening News” and” Scotsman” newspapers.
[2] Evidence for the Crown was led by Ms Karen Aitken, Procurator Fiscal Depute at Edinburgh. Mr Dominic Scullion of Messrs Anderson Strathearn, Solicitors, Edinburgh appeared on behalf of the Scottish Prison Service. No other parties were in attendance although Lothian Health Board was represented at the preliminary hearing on 2 April 2015.
[3] A joint minute was tendered covering a basic chronology and evidence was led by the Crown from Dr Craig Revill who works at Saughton prison as a general practitioner and Dr Duncan Birse who worked at the High Dependency Unit of Edinburgh Royal Infirmary. No further evidence was led on behalf of the Scottish Prison Service.
[4] The deceased had in the past sustained serious leg injuries in a road traffic accident which required him to walk with a stick. His mobility was limited to short distances and he used a wheelchair. As a consequence of the RTA he suffered from cellulitis and required regular medical treatment to bandage skin ulcerations two or three times a week (bi-lateral lymphoedema). This treatment continued whilst he was a serving prisoner. The deceased required to take a variety of medicines including furosemide, metformin, eliclazide, simvastatin, co-codamol and diclofenac. He also had Type 2 diabetes which had to be taken into account when treating him and prescribing medication.
[5] The deceased was born on 8 April 1948 and was sentenced to a period of two years’ imprisonment at Edinburgh Sheriff Court on 26 October 2011 and on 8 March 2013 at the High Court of Justiciary was sentenced to a total of four years’ imprisonment. In November 2013 he was continuing to serve the latter sentence at HMP Saughton, Edinburgh.
[6] Dr Revill was familiar with Mr Tait’s condition having examined him on 13 November 2013 when he complained of heartburn and feeling like having a “weight on his chest” Dr Revill referred Mr Tait to the Rapid Access Chest Pain Clinic which undertakes to see patients within 2 weeks.
[7] On 22 November 2013 Mr Tait’s legs were washed, bandaged and swabs taken from the ulcerations which were sent for analysis. On 23 November 2013 Mr Tait said he felt “shakey” and said he hadn’t eaten or taken much to drink. His heart and pulse rates were elevated but his blood/sugar level improved after he had eaten.
[8] The following morning on 24 November Mr Tait called for help in his cell. He could not get up, had a severe pain in his left leg and had suffered from diarrhoea. His temperature was high and his heart rate further elevated. As a result Mr Tait was conveyed to Edinburgh Royal Infirmary in a blue light ambulance and was admitted to a ward at 3 45pm that day
[9] Mr Tait had an unsettled night, was given medication and the dressings on his legs were replaced. He was transferred to a general medical ward. By 26 November his condition had improved slightly and he was drinking well but had little appetite. Mr Tait’s temperature had reduced slightly as had his heart rate but both were elevated. Intravenous fluids were considered no longer necessary and steps were taken to deal with blood sugar levels which had been affected by other necessary medication.
[10] By 27 November doctors treating Mr Tait were concerned that he was not responding to treatment, his legs were more swollen due to cellulitis and an x ray was ordered to check for gas gangrene, which proved negative.
[11]On 28 November Mr Tait began to feel unwell and had been vomiting perhaps as a reaction to some of the medication he had received. There was concern regarding worsening cellulitis and sepsis and Mr Tait was given a further review by a senior doctor who also addressed concerns regarding Mr Tait’s poor renal function.
[12] Mr Tait’s condition worsened further on 29 November when he suffered a cardiac arrest early that morning. He was moved to a high dependency unit where a steadily worsening renal dysfunction was noted and he continued to have a high temperature. Mr Tait was noted to have difficulty maintaining an airway and so was intubated. By 10 30 that morning his Glasgow Coma Scale was recorded as 3 (out of a possible 15).
[13] That afternoon microbiological results were received which suggested that Mr Tait might have caught a MRSA infection. Due to Mr Tait’s poor condition his next of kin Mrs Ross was contacted by hospital staff.
[14] Despite extensive support Mr Tait’s condition continued to deteriorate and the following morning after consulting with the next of kin the decision was taken to withdraw support. Mr Tait died about 30 minutes later at 11 10 am on 30 November 2013 with his niece present; a prison guard was on duty outside the room.
[15] On 3 December 2013 an autopsy was carried out by Dr Ralph BouHaidar. He noted that Mr Tait was of large build 5 ft. (152 cm) tall and weighed 19 st. 2
lb. (122 kg). There were no signs of injury. Mr Tait had an enlarged heart with dilated ventricles. A death certificate was issued after the autopsy listing the cause of death as:-
1a Clinically diagnosed multiple organ failure, pending laboratory studies.
[16] Further histological examinations led Dr BouHaidar to confirm the diagnosis that death had resulted from multi-organ failure, the autopsy revealed no other acute disease of significance. However Mr Tait’s history of chronic leg ulcers, diabetes and increased body mass index were significant factors which altered blood circulation in his legs and caused ulcer formation.
[17] As a result on 11 February 2014 Dr BouHaidar issued his autopsy report with an amended death certificate giving Mr Tait’s cause of death as
1a Clinically diagnosed multi-organ failure
1b Complications of cellulitis of the lower limbs
[18] I am satisfied that Mr Tait died of natural causes while in custody and I have no recommendations to offer. I found the evidence I heard credible and reliable and supplemented by copious prison and hospital records which provided detail of Mr Tait’s underlying health in recent years and his relatively sudden death due to the effects of cellulitis. I indicated at the conclusion of evidence that my verdict would be a formal one and I offer my condolences to the family.