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INQUIRY UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF HUGH DUNLOP

2014FAI24

 

SHERIFFDOM OF GLASGOW AND STRATHKELVIN AT GLASGOW

 

DETERMINATION by JOHANNA JOHNSTON, Queen’s Counsel, Sheriff of Glasgow and Strathkelvin following an Inquiry held at Glasgow into the death of HUGH DUNLOP, born 24.12.1952 who normally resided at Flat 10/1, 22 Dundasvale Court, Glasgow

 

 

Glasgow, 21 August 2014

 

PART I: INTRODUCTION

[1] This is an Inquiry under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 into the circumstances of the death of Hugh Dunlop who died in Her Majesty’s Prison Barlinnie, 81 Lee Avenue, Glasgow on 22 September 2013. His death was caused by ischaemic heart disease due to coronary artery atheroma.

 

[2] Mr Quither, Procurator Fiscal Depute appeared in the public interest. Ms McDonald, Solicitor, represented the Scottish Prison Service.

 

[3] The Inquiry heard evidence and submissions over the course of the 2 June 2014. The Crown led six witnesses in evidence and the evidence of three witnesses was received by affidavit. The parties entered into a joint minute of agreement in respect of the evidence of the pathologist who conducted the post mortem and the general practitioners from the surgery, which Mr Crosbie had attended in Castlemilk.

 

PART II: FINDINGS IN FACT

  1. As at 22 September 2013 Hugh Dunlop was 62 years of age. He normally resided at Flat 10/1, 22 Dundasvale Court, Glasgow.
  2. On 13 June 2013 Hugh Dunlop was sentenced to 24 months imprisonment at Glasgow Sheriff Court. He was conveyed to HM Prison Barlinnie on that date and detained there.
  3. On his admission to the prison, Hugh Dunlop was examined by two members of medical staff. There were no concerns about his health at that time. He was assessed as presenting no apparent risk in relation to his health.
  4. Hugh Dunlop had a history of benign prostate enlargement and high cholesterol prior to his admission prison. He had received treatment from his General Practitioner for these conditions. He had no medical history of chest or heart problems.
  5. On the 5 August 2013 Hugh Dunlop was examined by Dr Buksh at Barlinnie Prison. Mr Dunlop complained of having blood in his urine. Dr Buksh referred him to Glasgow Royal Infirmary.
  6. Mr Dunlop was given an appointment by the Glasgow Royal Infirmary for an examination on the 18 September 2013. The appointment was cancelled and rescheduled for the 25 September 2013.
  7. At around 09.00 on 22 September 2013 Martin Moy, then a prisoner in Barlinnie Prison, saw Mr Dunlop lying in bed in his own cell. He appeared to be asleep. Shortly before 1pm, Mr Moy went back to the cell and saw that Mr Dunlop was in bed and was still lying in the same position. He had blood coming out from his mouth. Mr Moy feared that Mr Dunlop was dead. He then alerted Prison Officers.
  8. Prison Officer Albert Matusavage answered the alert immediately and went into the cell. He saw Mr Dunlop lying in bed. Officer Matusavage saw that there was a trickle of blood at his mouth. There was no response when he shook Mr Dunlop. Officer Matusavage alerted other officers that there was an emergency and arranged for a nurse to attend.
  9. Nurse Jeanette Marshall attended minutes after she was called to attend. She saw that Mr Dunlop was lying on the bed. She checked for his pulse and noted there was none. She saw that he was not breathing and that his pupils were fixed and dilated. She noted that there was blood coming from his mouth. She noted that rigor mortis was present in all his limbs. She was of the view that he had been dead for quite a while.
  10. Dr Khoda Buksh attended and examined Mr Dunlop. He found no signs of life. At 1.45pm he pronounced Mr Dunlop dead.
  11. At 2.20 pm Police Officer Michael Clinton attended at Barlinnie Prison. He examined the cell where Mr Dunlop was lying. The officer found nothing suspicious in the circumstances.
  12. A post mortem examination was carried out on Mr Dunlop on 25 September 2013 at the Southern General Hospital in Glasgow by Dr Julie McAdam. The examination showed that Mr Dunlop had died as a result of ischaemic heart disease due to severe coronary artery disease.
  13. The post mortem examination revealed a slight enlargement of the prostate gland. There was no evidence of a malignancy in the tissue of the prostate gland. Examination of samples taken at post mortem showed no evidence of viral infection. The pathologists found features in the lungs and heart, which were entirely consistent with cardiac failure secondary to acute myocardial infarction.

 

PART III: DETERMINATION AS TO THE CIRCUMSTANCES OF THE                      DEATH

The Sheriff having considered all the evidence adduced FINDS AND  DETERMINES in terms of Section 6(1) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976:

 

  1. In terms of Section 6(1)(a) that;

Hugh Dunlop, born 24 December 1952 who normally resided at Flat 10/1, 22 Dundasvale Court, Glasgow died at Her Majesty’s Prison Barlinnie, 81 Lee Avenue, Glasgow at 13.35 hours on 22 September 2013.

  1. In terms of Section 6(1)(b) that ;    
  1. The cause of his death was :-

1a: Ischaemic heart disease

                due to

   b: Coronary artery atheroma ;

  1. In terms of Section 6(1)(c), (d) and (e) there are no circumstances of the death to be set out.

 

PART IV: NOTE ON EVIDENCE

  1. Mr Dunlop had no history of any cardiac problems. He had a history of high cholesterol. He had been treated for prostate gland enlargement trouble before his admission to the prison. When in prison, he had complained to fellow prisoners about having blood in his urine.
  2. Mr Dunlop was examined by Dr Buksh on 5 August 2013 and complained of blood in his urine. He was referred to hospital for further examination. He died before the scheduled appointment at the hospital.
  3. Mr Dunlop had had two teeth extracted several days prior to his death. He had suffered pain after these extractions and had been prescribed painkillers by the medical staff within the prison.
  4. The post mortem examination found no evidence of malignancy in the prostate gland and no evidence of any viral infection. In those circumstances, the pathologist concluded that the cause of death was heart disease and was not related to any problems Mr Dunlop had with his prostate gland or infection following upon the extraction of his teeth. The day before he died, Mr Dunlop had complained of feeling unwell. This was consistent with the evidence of a very acute myocardial infarction of around 12 to 24 hours duration prior to his death.  
  5. On the 22 September when Mr Dunlop was found in his cell and was unresponsive, medical staff were called for and attended without delay. On examination, there were no signs of life. There were no attempts at resuscitation as it was apparent that he had been dead for some time.
  6. Mr Dunlop had been seen at 9.30 that morning apparently asleep. There is nothing in the evidence to suggest that at any alarm should have been raised about his condition then. He had been complaining of feeling unwell and Mr Moy thought it best to let him sleep on. Mr Moy took the trouble to take lunch to Mr Dunlop at around 1pm and found him and alerted staff.
  7. Mr Dunlop was not seen by anyone between 9.30am and 1pm. Mr Moy is of the view that it is possible that Mr Dunlop was already dead when he saw him at 9.30 am. Nurse Marshall gave evidence that it was her view that he had been dead for quite a while when she examined him shortly thereafter. Accordingly, it is possible that Mr Dunlop had been dead for a number of hours before the alarm was raised by Mr Moy at around 1pm.  
  8. Police officers attended at the prison at around 2.20pm and saw Mr Dunlop still lying on the bed within the cell. The officers were satisfied that there was nothing suspicious in the circumstances surrounding his death.
  9. In light of all the evidence, I am satisfied that the death of Mr Dunlop was caused by natural disease, namely ischaemic heart disease and coronary artery atheroma.
  10. I wish to extend my condolences to the members of the family. It is very sad that Mr Dunlop died at a time when he was away from family and loved ones.

 

 

Glasgow, 21 August 2014.                                    Sheriff Johanna Johnston, Q.C.