INQUIRY UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF SAMUEL MOFFAT SMITH
SHERIFFDOM OF GRAMPIAN, HIGHLAND AND ISLANDS AT INVERNESS
[2016] FAI 11
B93/16
DETERMINATION
BY
SHERIFF MARGARET M NEILSON
UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRIES (SCOTLAND) ACT 1976
into the death of
SAMUEL MOFFAT SMITH
Inverness, 11 July 2016
The Sheriff, having resumed consideration of the Fatal Accident Inquiry into the death of Samuel Moffat Smith, Determines in terms of section 6 of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 as follows:-
In terms of section 6(1)(a)
The late Samuel Moffat Smith (date of birth 1 December 1949) died at 1.05 am on 11 May 2015 at Raigmore Hospital, Inverness.
In terms of section 6(1)(b)
The cause of Mr Smith’s death was:
I (a) haemorrhage, due to or as a consequence of (b) Dieulafoy’s lesion stomach;
II Cirrhosis and hepatocellular carcinoma due to hepatitis C infection and alcoholism.
Note
[1] Evidence in this inquiry into Mr Smith’s death was heard on 1 June 2016. The Crown was represented by Mr MacDonald, Procurator Fiscal Depute, Inverness. The Scottish Prison Service was represented by Mr Flannigan, Solicitor, Edinburgh.
[2] This was a mandatory inquiry, Mr Smith being in legal custody at the time of his death.
[3] Most of the evidence led was formal, consisting of a joint minute read into the record by Mr MacDonald. The joint minute incorporated a report by Dr Rosslyn Rankin, Consultant Pathologist, who carried out a post mortem examination on Mr Smith on 12 May 2015.
[4] In addition to the formal evidence, I heard evidence from three prison officers, Robert Henry Strong, Jacqueline MacAulay and Grace Cowan, all of HMP Porterfield, Duffy Drive, Inverness, who were the prison officers who were involved in Mr Smith’s care when he took ill in prison and, in the case of Ms Cowan and Mr Strong, who accompanied him to hospital.
[5] Mr Smith had been remanded at Inverness Sheriff Court on 27 April 2015 for sentence on 14 May 2015 and was held on the authority of that warrant.
[6] Mr Smith had a long history of alcohol and drug abuse and was hepatitis C positive. He was also a heavy smoker.
[7] While in custody he was seen by a prison doctor on 28 April and 1 and 4 May 2015.
[8] He was taken by ambulance to Raigmore Hospital, Inverness, on 9 May 2015 having taken ill in his cell. Prison officers responded to his call on the cell intercom system, saw that he was ill, and called the emergency services. The paramedics and ambulance arrived very quickly following upon the call. He was admitted to the intensive care unit and received blood transfusions.
[9] On 10 May 2015 he was transferred to theatre and various procedures were undertaken.
[10] He was transferred from the operating theatre to the intensive care unit at 11.30 am on 10 May but his condition remained poor, with further bleeding and multi-organ failure in spite of full medical support. He died at 1.05 am on 11 May 2015.
[11] The post-mortem examination, which was limited due to the presence of hepatitis C infection, revealed a small gastric ulcer, although microscopically this did not show any evidence of a bleeding point. It was more likely, therefore, that the source of haemorrhage was the Dieulafoy’s lesion. At post-mortem, no fresh bleeding was found in the stomach or the remainder of the intestinal tract. Post-mortem examination also revealed liver cirrhosis and hepatocellular carcinoma, complicating hepatitis C infection which would have been associated with a poor prognosis in any event.
[12] It was clear from the evidence of the three prison officers that as soon as Mr Smith was taken ill on 9 May, immediate steps were taken to call the emergency services and have him transferred to Raigmore Hospital in Inverness. This was a medical emergency which could not have been foreseen by prison staff. The care he received from all of the prison officers, and indeed the paramedics and hospital staff, was exemplary.
[13] The court extends its condolences to the family of the deceased.