NoRes2024FAI_007
Submitted: 19 April 2024
Form 6.3
Notice
SHERIFFDOM OF CENTRAL, TAYSIDE AND FIFE AT PERTH
Court ref: PER B17-20
NOTICE
UNDER THE INQUIRIES INTO FATAL ACCIDENTS AND SUDDEN DEATHS ETC. (SCOTLAND) ACT 2016
IN THE
INQUIRY INTO THE DEATH OF SCOTT ANDREW ROSS
Court ref: PER B17-20
1. The determination of the sheriff in this inquiry was issued on 27 February 2024.
The Sheriff made the following recommendations:
1. There should be a co-ordinated approach between the hospital and the prison systems in the management of a prisoner’s drug withdrawal.
2. Those managing benzodiazapine withdrawal should consider carefully the proper dosage required for safe discontinuation. Under-prescription in respect of benzodiazapine discontinuation may cause seizures, which 8 can cause brain damage and death; the expert evidence was that overprescription was less harmful than underprescription.
3. NHS Tayside staff both in prison and in hospitals should consider the existing protocols relating to drug withdrawal. The protocols should be fit for purpose and, where appropriate, tailored to fit the needs of individual prisoners. The requirements for safe opiate withdrawal and safe benzodiazapine withdrawal are unlikely to be the same.
4. All NHS staff should be supported in their care of prisoners withdrawing from illicit substances by being able to seek expert support and advice.
5. A patient’s reported use of illicit drugs ought to be taken into account and not ignored or disbelieved - particularly where there is evidence of such abuse (such as urine samples) and observed withdrawal seizures.
6. More generally, there must be a co-ordinated approach between NHS staff in prison and those working in hospitals in relation to the timely and expeditious passage of clinical information in respect of a patient moving from one facility to another.
2. The Scottish Courts and Tribunals Service has not received a response from the Scottish Prison Service within the time limit prescribed in the Act being 18 April 2024.