Scottish Sheriff Court Decisions

SHERIFFDOM OF LOTHIAN AND BORDERS AT EDINBURGH   2011FAI 50   Case Number: 2B 9/2011
	Determination by   SHERIFF FRANK RICHARD CROWE Re   Inquiry held under the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976 Section 1(1) (a)   Into the circumstances of the death of RAYMOND HOLLAND (date of birth 20 June 1969)             ­­­­­­­­­­­­­­­­­________________

 

 

 

EDINBURGH 8^th November 2011

 

The Sheriff determines as follows:-

[1] In terms of section 6(1)(a) of the said 1976 Act that Raymond Holland who was born on 20 June 1969 and late of Her Majesty's Prison Saughton Edinburgh died at 17 55 hours on 29 April 2010 at Ward 118 of the Intensive Care Unit 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

I (a) Clinically diagnosed multi-organ failure

I (b) Pneumococcal pneumonia

II Chronic HIV infection

Liver cirrhosis

 

[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

[6] This inquiry relates to the sudden death of a life sentence prisoner Raymond Holland, aged 41 who died when in custody on 29 April 2010. The inquiry took place at Edinburgh Sheriff Court on 2 November 2011.

 

[7] Evidence for the Crown was led by Mr James O'Reilly, Procurator Fiscal Depute at Edinburgh. Ms Lorraine Walkinshaw appeared for Scottish Ministers representing the Scottish Prison Service. The family of the late Raymond Holland were not represented at the inquiry.

 

[8] Evidence was led from the following witnesses. Dr. Ralph BouHaidar BSc MSc MD FRC Path. and Ms Jane Officer BSC (Hons) MSc. The remaining evidence was adduced by way of joint minute of agreement and reference to relevant documents and statements. No evidence was led on behalf of Scottish Ministers.

 

[9] The petition seeking an Inquiry had been presented by the Procurator Fiscal on 5 January 2011. An Inquiry was fixed for 20 June 2011 but on joint motion this was adjourned until November to allow parties further time to prepare. At that stage Ian McCarry Solicitors Glasgow appeared on behalf of Mr. David Holland the deceased's brother and next-of-kin. In the event the family were not represented at the Inquiry.

 

The Facts

 

[10] The following facts were either admitted or proved in evidence:-

 

1. Raymond Holland (hereinafter referred to as "the deceased") had been sentenced to life imprisonment for murder about 20 years ago and was released from prison in 2003 but recalled from parole in 2006 and remained in prison until the end of 2008/ beginning of 2009 when he was released on licence. He was however recalled to prison in February 2010 after a further breach of licence conditions.
2. The deceased had been tested positive for the HIV virus in June 1993 and was tested positive for Hepatitis C in July 1993. He had a history of drug abuse and while at liberty in recent years was known to drink alcohol heavily.
3. In July 1998 the deceased was prescribed anti-retro viral medication to combat the effects of the HIV virus and improve his immune level. In February 2010 the deceased's CD4 cell count was measured at 403. A normal cell count is about 500 and an individual would become very prone to infection if the count dropped below 200.
4. While in Saughton prison in 2010 the deceased was prescribed 80 mgs methadone per day and 20 mgs of diazepam twice daily. Initially the diazepam was dispensed to the deceased in blister packs with his daily anti-retro viral medication and the deceased was allowed to manage these drugs himself. Methadone was dispensed daily to the deceased by prison medical staff.
5. In March 2010 prison staff suspected a visitor had attempted to supply the deceased with drugs during a supervised visit. Around this time prison staff had concerns the deceased was consuming his prescribed diazepam in an irregular manner. As a result prison staff took over dispensing diazepam to the deceased daily.
6. The deceased was unhappy at the change in dispensing arrangements for diazepam and although he kept taking methadone and diazepam at the daily dose he stopped taking anti-retro viral medication.
7. The deceased was unwell on the morning of 27 April 2010. He was able to attend for his methadone prescription but returned to bed and later was sick. He was attended to by a prison nurse but was uncooperative. He was sitting in a chair at that time and it was decided to maintain observations. After being sick again he was seen by prison medical staff that afternoon- a doctor and the nurse but would no cooperate with a medical examination. The deceased was well enough to attend at the prison dispensary at 5 30pm that day for his diazepam prescription.
8. The following morning the deceased's cell-mate, Dominic Russell, who had noticed Raymond Holland had been unwell in the night, contacted staff as he noticed a further deterioration in the deceased's condition.
9. The deceased was attended to by prison medical staff around 8am. He was found to be incoherent and had a reduced level of consciousness. He had a fast heart rate and low blood/sugar and blood oxygen levels. An ambulance was summoned as an emergency and it arrived at the prison at 8 12 am and thereafter conveyed the deceased to Edinburgh Royal Infirmary about an hour later after paramedics had administered treatment at the locus.
10. The deceased was admitted to the intensive care unit of the hospital as he was diagnosed to be suffering from a severe multi lobar pneumonia of the left lung and multi organ failure. The deceased was placed on a ventilator and was noted as being in severe septic shock and was not responding to treatment. He was also suffering from severe kidney failure and liver failure. The latter due to alcohol induced cirrhosis and chronic liver disease as a result of hepatitis C.
11. By 9 30 pm on 28 April 2010, hospital staff considered all therapeutic options had been explored and thought that the deceased's prospects of survival were poor. Nitric oxide was administered which stabilised the deceased's condition overnight.
12. By the morning of 29 April 2010 the deceased's condition had further deteriorated and adrenaline was administered. The deceased's condition further deteriorated and with the consent of Mr. Holland's family life support apparatus was switched off. The deceased died at 5 55pm and life was formally pronounced extinct by Dr. Andrew Sutherland at 6 15 pm.
13. An autopsy was carried out on 4 May 2010 by Dr. BouHaidar and Professor Kernbach-Wighton. After receiving toxicology results the pathologists gave the causes of death listed above.
14. There was a discrepancy between the drugs found in samples taken from the deceased on admission to hospital on 29 April and post mortem at autopsy on 4 May. The former were negative for drugs whereas the latter revealed therapeutic levels of methadone and diazepam. From 8 am on 28 April 2010 until his death the deceased was supervised at all times by prison staff and no drugs of this type were taken or administered during this period. The positive post mortem test results were as a result of the body of the deceased naturally redistributing traces of drugs from organs after death.
15. There were no suspicious circumstances or matters giving rise to concern surrounding the deceased's death.

Discussion of the Circumstances

 

[11] It was apparent from the evidence led and provided to me that the deceased had had a long history of drug abuse during which he became infected with the HIV and Hepatitis C viruses. The former was not problematic until 1998 when the deceased was prescribed anti-retro viral medication to maintain his immune level and reduce susceptibility to infection.

 

[12] Although the deceased had been a life sentence prisoner for most of the 20 years prior to his death he had been at liberty on parole from 2003 to 2006 and from 2008 to early 2010. During these periods the deceased abused alcohol as well as drugs and as a result suffered from cirrhosis of the liver.

 

[13] On recall to Saughton Prison from life licence in February 2010 the deceased was prescribed methadone in respect of his drug dependency and anti-retro viral medication and diazepam for the HIV and Hepatitis C viruses. The former was administered daily to the deceased by prison medical staff and the latter was taken by the deceased he having been entrusted with that medication by staff at Western General Hospital, Edinburgh who had monitored his condition for a number of years.

 

[14] The deceased was regarded by prison staff as normally compliant and was a trusted Passman who was given certain duties to perform within the prison. However the deceased became agitated when about a month prior to his death prison staff altered medication arrangements to dispense diazepam twice daily rather than allowing the deceased to take it himself.

 

[15] The deceased continued to receive methadone and diazepam daily as prescribed but stopped taking anti-retro viral medication as a protest although he was warned several times by prison and medical staff that stopping this medication would make him more susceptible to infection.

 

[16] When the deceased's cell-mate became concerned about Mr. Holland's health, prison medical staff attended promptly and appropriately. While the deceased did indicate to staff about lunchtime on 27 April that he felt unwell and ought to be admitted to hospital he would not cooperate with an examination. Staff were left to make a visual examination and did not consider the deceased looked little worse than his usual presentation. Signs of laboured breathing only became apparent the following morning and an ambulance was summoned and attended promptly.

 

[17] The deceased was taken to hospital and after a brief assessment in Accident and Emergency was transferred to intensive care by which time he was in a coma. As required by prison rules the deceased was guarded by staff during his time in hospital.

 

[18] The only significant feature of inquiries related to the discrepancies between hospital and post mortem blood samples. I found the evidence I heard from Dr. BouHaidar and Ms Officer credible and reliable. DNA testing had been carried out on both samples to confirm they both came from the deceased. The samples were re-tested to eliminate the possibility of rogue results or any cross contamination or mix up. While Ms Officer considered the results outwith the normal range for post mortem re-distribution she considered this was a possibility. Had she not had the hospital samples Ms Officer would have been content that the post mortem samples were consistent with the deceased's medial history of taking methadone and diazepam on a long-term basis. This results in residues of these drugs leaching out of the organs in the body back into the blood stream post mortem.

 

[19] Although the deceased had stopped taking anti-retro viral medication about a month prior to death this would not of itself according to Dr Andrews of the Western General Hospital have led to his death. Dr Andrews last saw the deceased on 1 April 2010 when his condition appeared the same as at previous appointments. The deceased could not be persuaded to resume the medication.

 

Decision

 

[20] It is clear from the evidence that in the months prior to his death Mr. Holland was not in a good state of health because of the underlying conditions of HIV, Hepatitis C and cirrhosis of the liver. The deceased became unwell on 27 April 2010 and symptoms of pneumonia were not detected until the following day. Although admission to hospital and specialist treatment was immediate thereafter such was Mr Holland's underlying state of health that he quickly lapsed into a coma and he succumbed to multi organ failure as a result of pneumococcal pneumonia. This eventually affected both lungs but was more apparent in the left lung. Mr. Holland was unable to respond to all known forms of treatment due to the chronic HIV infection which he suffered and cirrhosis of the liver which resulted from alcohol abuse and Hepatitis C.

 

[21] Ultimately the deceased's family had the painful decision to take with medical staff to switch off life support machines when no further treatment could be offered and Mr. Holland's condition continued to deteriorate beyond any hope of recovery.

 

[22] Having heard the evidence I was able to issue a formal verdict. Latterly Mr. Holland was in a poor state of physical health as a result of past abuse of drugs and alcohol. His decision to cease taking anti-retro viral medication was freely taken and one which he could not be dissuaded from. I found no evidence to suggest that anything could have been done differently which might have prevented Mr. Holland's death.