INQUIRY UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF ALBERT RITCHIE STEPHEN COSGROVE
SHERIFFDOM OF TAYSIDE, CENTRAL AND FIFE AT PERTH
[2016] FAI 2
DETERMINATION
of
SHERIFF W M WOOD
Under the Fatal Accident and Sudden Deaths Inquiry Scotland Act 1976
in respect of
the Fatal Accident Inquiry into the death of
ALBERT RITCHIE STEPHEN COSGROVE
(born 9 May 1969)
Perth, 18 December 2015
The sheriff, having considered the cause, determines:-
[1] In terms of section 6(1)(a), Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 (“the 1976 Act”) that Albert Ritchie Stephen Cosgrove, born 9 May 1969, formerly residing in Dundee and latterly a prisoner in Her Majesty’s Prison, Perth, died within cell 53 in “C” hall, there, on Sunday 4 January 2015.
[2] In terms of section 6(1)(b) of the 1976 Act, the cause of death was upper gastro‑intestinal haemorrhage.
NOTE
The Evidence
[1] Evidence in this inquiry was led on 25 November 2015. The Crown was represented by Ms Ross, Senior Procurator Fiscal Depute, Dundee; Mr Findlay, solicitor, represented Ms Patricia Barron (the nearest relative of the deceased); Ms Phillips, solicitor, represented the Scottish Prison Service; and Ms McPhail represented Tayside Health Board.
[2] The Crown led evidence from Dr Mark Anthony Wallace (general practitioner, Perth Prison), Wayne David Crooks (prison officer), Robert Michael Simpson (a prisoner), Jacqueline Anne Robertson and Fiona Mary Scott (both nurses, Perth Prison), Stuart Fraser Wilkie (paramedic), Dr Helen Brownlow (consultant forensic pathologist) and Detective Constable Neil McVean.
[3] In terms of a joint minute, it was accepted by the parties in attendance that:-
1. Albert Ritchie Stephen Cosgrove (the deceased) was lawfully held as a prisoner in Perth Prison in accordance with warrants of imprisonment.
2. Crown production number 4 is a disk containing copied CCTV footage of the area outside cell 53 in ‘C’ Hall, HMP Perth (“the deceased’s cell”) between 1617 hours and 1716 hours on 3 January 2015.
3. Crown production number 5 is a disk containing CCTV footage of the area outside the deceased’s cell between 0753 hours and 0842 hours on 4 January 2015.
4. Crown production number 6 is a disk containing CCTV footage outside the deceased’s cell between 0840 hours and 0933 hours on 4 January 2015.
5. The deceased’s life was pronounced extinct at about 0945 hours on 4 January 2015, in accordance with the Pronunciation of Life Extinct Form (Crown production number 7) as completed by Stuart Wilkie of the Scottish Ambulance Service. The condition unequivocally associated with the death was “post mortem staining”.
6. The deceased’s body was conveyed to the mortuary at Sir James Black Building, West Bell Street, Dundee.
7. On the instructions of the procurator fiscal, Perth, a post mortem examination was performed upon the deceased’s body on 7 January 2015, the findings of which are contained within Crown production number 10. The medical cause of death is recorded in the post mortem report as “upper gastro‑ intestinal haemorrhage”.
8. Crown production number 2 is a printed copy of the deceased’s prison electronic medical records.
9. Crown production number 3 is the deceased’s prison medical records.
10. Crown production number 8 is the Intimation of Death form submitted to the procurator fiscal at Dundee.
11. Crown production number 9 is a book of photographs depicting views of the communal landing, the security tag placed on the cell and views into and around the area of cell 53, including the deceased.
12. A copy of productions 1 and 2 lodged by the Scottish Prison Service where cell alarm activation records for the deceased’s cell for the period 31 December 2014 to 4 January 2015. The cell alarm was last activated by the deceased on 2 January 2015 at 12:21:57 hours.
[4] No evidence was led otherwise on behalf of Ms Barron, Tayside Health Board or the Scottish Prison Service.
Submissions
[5] In submissions, all parties were agreed on the findings in terms of section 6(1)(a) and section 6(1)(b) in respect of the cause or causes of death. None of the parties invited me to make any findings in terms of section 6(1)(c), (d) or (e).
Determination
[6] The evidence in the present inquiry gave no rise to any dispute. Witnesses were subject only to extremely limited cross‑examination, at most. I found all of the witnesses to be credible and reliable.
[7] Dr Wallace spoke to the medical records held about Mr Cosgrove. A qualified doctor, he has been a general medical practitioner (“GP”) since 2005 and a GP in the prison service for eight years, of which six years had been serving Perth Prison. He confirmed that Mr Cosgrove had regularly required medical services within the prison setting, including engagement with the addictions team. Dr Wallace had referred Mr Cosgrove to a consultant gastroenterologist in September 2012 as a result of concerns regarding a longstanding diagnosis of oesphagitis. Although Mr Cosgrove had a medical history that included chronic obstructive pulmonary disease, subarachnoid haemorrhage, drug abuse, a serious overdose (in April 2012 resulting in kidney failure and a prolonged admission to the intensive care unit) and Wolff Parkinson White syndrome (relative to Mr Cosgrove’s heart function), none of these were ultimately related to the cause of death. The deceased had a long history of dyspepsia and reflux and he had also been diagnosed with gastro‑ oesophageal reflex disease (“GORD”). Dyspepsia can lead either to bleeding into the stomach (often presenting as blackened stools or vomiting) or haemorrhage from the stomach lining. Mr Cosgrove’s symptoms, however, were controlled by omeprazole and his conditions were “chronic” rather than “acute”; there was nothing of any real concern in his presentation. As a result of the referral Mr Cosgrove had been offered an appointment at Perth Royal Infirmary for an endoscopy on 26 October 2012, which he had refused to attend.
[8] Throughout his time in prison, Mr Cosgrove’s symptoms had always been investigated and kept under review, although he often failed to respond to or refused to attend arranged consultations. Dr Wallace had last seen Mr Cosgrove in respect of an unrelated matter on 17 November 2014 in order to review his prescription for pregabalin. Mr Cosgrove had been prescribed that for a trapped nerve in his chest, but while he no longer needed it for that he wished that prescription to continue to help with his anxiety. Dr Wallace referred him to the mental health team for further assessment in that regard and an appointment was made for 24 November. Later that day (17 November), Mr Cosgrove had self-referred with a stomach complaint and saw one of Dr Wallace’s colleagues. He subsequently declined to attend the mental health referral. He was seen by the addictions team nurse for a methadone review on 15 December 2014 when he had been optimistic that he would be transferred to the Castle Huntley Open Prison in February 2015. He had scalded his foot on 1 January 2015 and the wound had been cleaned and dressed.
[9] Cross‑examined, Dr Wallace confirmed that Mr Cosgrove had a history of seizures. These could have been caused by an aneurism sustained in 2005; by the drugs that he had historically abused; or as a result of a chest infection. These would not have had any effect on his oesophagus. Dr Wallace explained the difference between dyspepsia (which primarily concerns the stomach) and GORD (a disease of the oesophagus). Both of these could be chronic conditions although both can sometimes be eradicated by treatment. Dr Wallace explained that prisoners often refused to attend clinics or appointments: for obvious reasons, they were not told of the date and time of appointments in advance; sometimes their conditions had resolved or their priorities changed. In relation to the prescription of pregabalin, there was no need for that to be stopped as it could be a mood stabiliser as well as a painkiller. At his meeting with Mr Cosgrove, the latter had not mentioned any problems with his stomach. Although it was possible that a person such as the deceased might vomit blood, this would normally be a presentation of worsening gastritis. Internal stomach bleeding could be a symptom of dyspepsia, but this would not normally present as a severe or acute condition (although it could be) and it would not normally require hospitalisation. Dr Wallace confirmed that, as far as he was concerned, there was no cause for undue concern about Mr Cosgrove or his condition from his observations prior to Mr Cosgrove’s passing in January 2015.
[10] Prison officer Wayne Crooks described his duties on the evening of Saturday, 3 January 2015 and the events of 4 January 2015. Mr Cosgrove’s fellow prisoner, Robert Simpson, spoke to the finding of Mr Cosgrove in his cell on Level 4 of C Hall. Mr Crooks confirmed that he had been on duty between 0800 hours and 1730 hours on 3 January 2015. He confirmed that the prisoners were locked in from 5.00pm and staff were responsible for patrolling the halls from 5.30pm onwards. He could not recall seeing Mr Cosgrove that day specifically. Mr Crooks returned to duty at 8.00am on Sunday, 4 January 2015. In common with prison routine, his first job of the day was a “numbers check”. In doing that, he collected the keys to the cells and, while he issued the morning milk ration to each cell, he would also carry out a physical numbers check of the prisoners in each cell. Assuming that the numerical count was correct, then the normal daily routine would commence. In carrying out the numbers check, Mr Crooks would unlock the door; enter; obtain a response (of any kind) from the prisoner within; exit the cell and lock it; and then proceed to the next cell. He was aware of the importance that he obtained a response from each prisoner, as this was a required procedure (confirmed by production number 3 for the Scottish Prison Service).
[11] In relation to Mr Cosgrove’s cell (number 53), he recalled that he had unlocked the door, entered, placed the milk on a shelf inside the cell and noted that Mr Cosgrove had made a noise in his sleep; he then left the cell and carried on with his rounds. He did not see or smell anything untoward; in particular, he did not see or smell any blood or vomit. The lights in the cell were off (although the light in the toilet area was triggered by a movement sensor, providing some light) and Mr Cosgrove had appeared to be asleep. Mr Cosgrove’s cell had been the second to last one for him to check on that level, and the order was subsequently given to unlock the doors. As part of the “unlock” procedure, no one was required to enter any of the cells; the doors were simply unlocked.
[12] Mr Simpson recalled being asked to go and fetch Mr Cosgrove from his cell in order to collect his medication. When he went in, he noted that the room was in darkness and that Mr Cosgrove was lying in his bed. Mr Cosgrove was unresponsive. Mr Simpson felt for a pulse, but could not feel one and he then activated the alarm buttons and returned to the doorway in order to wait for staff to arrive. He did not recall noticing any smell, but noted that there seemed to be blood under the bed. When the staff arrived, they asked him to leave, which he did. He noted that Mr Cosgrove had looked as if he was asleep, on his side facing the wall. He had hovered around the door, going in and out whilst he waited for staff to arrive.
[13] Mr Crooks had been at the “officer’s station”, which was situated in the middle of the level, with cells running away from it on both sides. He responded to Mr Simpson’s alert and, on arrival, found Mr Simpson crouched beside Mr Cosgrove. He recalled that Mr Cosgrove had been lying on his bed, which ran along the left hand wall from the door. His head was at the door end of the bed, as normal. He noted blood and vomit on the bed and around the floor area. He recalled an overwhelming smell of vomit that had not been there on his first visit of the day. He asked Mr Simpson to leave (which he did) and then radioed to ask for assistance from the nurse. He checked for a pulse. He also asked for his manager, Colin Watson, to attend. The first nurse to arrive was Jacqueline Robertson. He told her that he could not feel a pulse. Fiona Scott was also summoned.
[14] Jacqueline Robertson is 41 years of age and has been qualified as a nurse for seven years. Fiona Scott, who is the same age, qualified as a nurse in February 1999. Ms Robertson has worked at Perth Prison for about 13 months and Ms Scott for about 20 months. Both had been dispensing drugs from about 8.00am that day, initially on level 3 and then on to level 4. The message that was passed to them was that one of them should go and see Mr Cosgrove, as he “wasn’t feeling well”. Ms Robertson responded, and went to cell 53. On arrival, she saw Mr Cosgrove lying on his bed with his head towards the door. She thought his position was “unnatural” in that his head was facing away from the wall, with his left armed crossed above it, holding on to the bedframe while his right arm was hanging out the right hand side of the bed. She saw blood on the floor – mainly under the bed – that resembled coffee grounds. She also noted that there seemed to be blood splash in the sink, although not a lot. She noted blood on Mr Cosgrove’s mouth. When she checked his wrist for a pulse, she could not find one and she noted that Mr Cosgrove was cold to the touch, with some mottling of the skin. She was aware that this can happen when the blood stops circulating and she believed then that Mr Cosgrove had passed away. With Mr Crooks’ assistance, they turned Mr Cosgrove onto his back. She asked him to summon Fiona Scott and to call a “code blue”. In accordance with their protocols, Ms Scott commenced CPR (that is, cardiopulmonary resuscitation). As Mr Cosgrove did not appear to be breathing a “code blue” alert (for prisoners with breathing difficulties) was called. Ms Robertson returned to the health centre to get a “crash bag” that contained, among other things, a blood pressure cuff, thermometer, saturation monitor and pen torch. She also obtained the emergency bag that held a mask for resuscitation, with oxygen. An airway was inserted and towels were put down on the floor due to the risk of slippage. CPR continued for about 15 minutes before ambulance technicians arrived. She could not say how the splash marks in the sink had been caused. Ms Robertson’s assessment from the outset was that Mr Cosgrove had passed away.
[15] Ms Scott recalled that, whilst she was conducting CPR, electrodes had been fitted to Mr Cosgrove’s chest, but there was no sign of life at any time. She had noted mottling of Mr Cosgrove’s skin at the back of his legs where the blood had pooled. She, too, had seen the blood in the sink and thought that perhaps food had been vomited there. She did not recall any smell. She recalled that they had carried out CPR on Mr Cosgrove for about 25 minutes until the ambulance technicians arrived. She confirmed that she had been in attendance at cell 53 from about 0910 hours on 4 January 2015.
[16] Neither the prison nurses nor ambulance technicians have the necessary qualifications to pronounce life extinct. This would normally be done by a doctor or a paramedic.
[17] Stuart Wilkie is 43 years of age and has been a paramedic for about 18 years. He had received instructions to go to Perth Prison at about 0916 hours on 4 January 2015 in order to deal with an unresponsive male prisoner. He had got there at 0937 hours and found staff and ambulance technicians performing CPR. He could tell that Mr Cosgrove had aspirated (that is, inhaled vomit) and he noted signs of “post‑mortem staining” – the technical term for mottling of the skin on the lower part of the body. He noted that the ambulance crew in attendance had already tried to clear Mr Cosgrove’s airway. He noted that Mr Cosgrove was attached to the defibrillator and that he was noted as being “asystole” (that is, “flatline” showing no electrical activity in the heart), and had been since 0924 hours. From his training, he was aware that post‑mortem staining was a feature incompatible with life and he pronounced that life was extinct at 0948 hours. In his view, there was nothing that could have been done that had not been done and he allowed CPR to continue until he had a clear understanding of the facts. He had never known post‑mortem staining to develop within 30 minutes of death.
[18] Dr Helen Brownlow is 37 years of age and a consultant forensic pathologist. She confirmed the terms of the post‑mortem report. Although the preliminary report had been prepared by Dr Graham Whyte, Dr Whyte had since passed away and she had therefore completed a supplementary section to it. It had been noted that the deceased’s stomach had contained large amounts of brown fluid (approximately 400 millilitres), with a consistency of “altered” blood and a characteristic “coffee ground” appearance. This is because blood changes in the stomach due to interaction with the acids there. The amount of blood in the stomach and the amount of blood at the locus would collectively constitute a large proportion of the deceased’s circulating blood volume. The lining of the stomach showed inflammation consistent with acute gastritis. It had been difficult to identify a single bleeding point at post‑mortem due to changes in the stomach lining and the fact that large bleeds can occur over a prolonged period of time due to erosion/inflammation of a large area of the stomach lining. Although the post‑mortem indicated that there had been aspiration of stomach contents into airways on both sides, this was likely to have happened post‑mortem due to the loss of the “gag” reflex. Although the deceased’s stomach would have been bleeding, a person might be unaware of that and be asymptomatic; alternatively, it may present as indigestion or mild abdominal pain. None of the other organs showed any significant damage due to alcohol or drug use taking into account the deceased’s age. A minor degree of thickening of the heart walls was attributed to general wear and tear changes. An examination of the deceased’s blood confirmed the presence of methadone, pregabalin and etizolam. The latter is a benzodiazepine not currently controlled in the UK, but medical literature contained no reports of fatalities that were attributed solely to its use. The death was attributed to haemorrhage from the upper gastro‑intestinal tract.
[19] In her experience, post‑mortem staining occurs from about 30 minutes after death, although it may take longer where there is reduced blood volume. It was entirely possible that the blood on the floor of Mr Cosgrove’s cell had also occurred post‑mortem through draining of the stomach contents. Although some blood may have been vomited onto the floor, it was most likely that this would have happened after the deceased had slipped into unconsciousness or that the stomach contents had drained out after death. It was likely that Mr Cosgrove would have had some vomiting while sitting or standing (leading to the splash marks on his leg and foot) and he would have subsequently have lost blood pressure and fallen unconscious. He was likely to have been in that condition when he passed away.
[20] Clearly, while Mr Cosgrove appears to have been a man with multiple health issues, none of them appeared to be life threatening on presentation in the weeks leading up to his death. He had longstanding diagnosis of disease relating to his oesophagus and gastro‑intestinal tract, although the extent of the damage to his stomach could not reasonably have been known by the prison authorities or medical staff responsible for his treatment. It is clear that Mr Cosgrove’s death could not have been anticipated and that the treatment with which he was provided by the medical staff at the prison was entirely appropriate. In my view, the medical staff are to be commended for commencing CPR in circumstances where they must have known or had reasonable cause to strongly suspect that Mr Cosgrove had passed away and – in accordance with their protocol – continued to administer CPR for more than 30 minutes before Mr Wilkie arrived and was able to declare life extinct.
[21] I must say that I am concerned that there appeared to be little urgency attached to the message given to medical staff from the prisoner officers, given that the nurses were wholly unprepared for what they found on entering Mr Cosgrove’s cell. From the evidence I heard, the fault would appear to lie with whoever passed the message on from Mr Crooks, although it remains unclear. The prison nurses should obviously have been told that Mr Cosgrove was unresponsive and apparently unconscious – which would no doubt have instilled a sense of urgency and enabled them to assess that they would need some emergency equipment from the outset – rather than the rather inadequate message that Mr Cosgrove “wasn’t feeling well”. Be that as it may, in the circumstances of Mr Cosgrove’s passing, any increased level of urgency would not have made any difference to the outcome as it is likely that he passed away some time shortly after 0800 hours on 4 January 2015.
[22] Finally, I should like to extend my sympathy to Mr Cosgrove’s family. I suspect they, like me, will have found the post‑mortem report difficult to understand and it will no doubt be of some comfort to know that Mr Cosgrove’s eventual passing is likely to have happened when he was unconscious and unaware of the seriousness of his condition.