Scottish Sheriff Court Decisions

SHERIFFDOM OF GLASGOW AND STRATHKELVIN AT GLASGOW

 

 

INQUIRY HELD UNDER FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 SECTION 1(1)(a)(ii))

DETERMINATION BY LINDA MARGARET RUXTON, Sheriff of the Sheriffdom of Glasgow and Strathkelvin following an Inquiry held at Glasgow on the 29, 30 September and 1 October all Two Thousand and Nine into the death of COLIN STEIN CROCKWELL

 

 

 

GLASGOW, 9 October 2009.

The Sheriff, having resumed consideration of the evidence, joint minute of agreement, productions and the submissions thereon

 

FINDS IN FACT

that

(1) Colin Stein Crockwell was born on 12 October 1971.

(2) On 19 August 2008 he was admitted to Her Majesty's Prison, Barlinnie, Glasgow having been sentenced at Glasgow Sheriff Court to a period of five months imprisonment.

(3) He was received into the prison at 1600 hours on 19 August 2008. As part of the standard admissions procedure, he was interviewed by the admissions officer and the admissions nurse practitioner. He did not see not the duty medical officer at that time.

(4) It is prison protocol that all prisoners are seen by a doctor within 24 hours of admission.

(5) During his admission interview Mr Crockwell told the nurse that he had problems with alcohol and drugs. He was prescribed 30 mls of methadone daily. He also disclosed that he suffered from epileptic seizures for which he was prescribed Epilin, an anti-convalescent drug. He had a history of alcohol dependency and related seizures, drugs misuse and Hepatitis C infection.

(6) No particular concerns about his health were expressed or noted at the time of his admission and Mr Crockwell himself made no complaint of feeling unwell.

(7) At about 1830 hours during a routine check of his cell, Mr Crockwell was found to be having some sort of seizure. Nursing staff were quickly in attendance.

(8) Dr Buksh, one of the prison medical officers, also attended and found Mr Crockwell to be recovering from his seizure. At that time he was conscious, responsive but confused. Nurses had earlier recorded his blood pressure as high at 240/160.

(9) After 10 to 15 minutes, Mr Crockwell regained his normal senses and had recovered. His blood pressure was again measured and found to be 140/100 which was in the upper range of normal. His pulse was steady and also within normal range. A blood sugar test confirmed that he was not diabetic.

(10) His seizure was diagnosed as having been caused by alcohol withdrawal. Dr Buksh commenced a detoxification regime for alcohol and prescribed Librium, a type of tranquillizer which was prescribed to prevent further seizures, delirium tremens and reduce cravings for alcohol. 40 mgs of Librium was administered by nursing staff at 7.25 pm.

(11) In accordance with standard procedures, following Mr Crockwell's seizure nursing staff raised a medical marker, highlighting his condition and alerting residential officers to the need to be alert to any symptoms indicative of further seizures. Mr Crockwell was moved from the fourth floor to the ground floor for safety reasons and so that he would be nearer to nursing staff. He was placed on strict hourly observations requiring staff to carry out a visual check via the observation hatch. Residential staff were aware that Mr Crockwell had suffered a seizure.

(12) No concerns about Mr Crockwell's health or well-being were noted during the night which passed uneventfully.

(13) At about 7.30 am on 20 August, Mr Crockwell was escorted to the nearby nursing station where he received his medication - a further 40 mgs of Librium. He gave the nurse no cause for concern at that time.

(14) Prison officer Alan Gilmore escorted Mr Crockwell to and from his cell. He had a brief conversation with him. Mr Crockwell appeared to be suffering from alcohol withdrawal, his condition being described as "quite rough - as if he had a hangover". Mr Crockwell made no complaint of feeling unwell but he refused breakfast.

(15) Hourly observations continued during the course of the morning. Mr Gilmore checked Mr Crockwell at 9.10 am and 10.20 am. During that period, no concerns were noted and Mr Crockwell made no complaint of feeling unwell.

(16) Each cell has an emergency call button should assistance be required. The emergency call button in cell 1/7 was not activated at any time.

(17) At approximately 11.40 am, officer Gilmore opened the cell door and found Mr Crockwell lying on his bed with his arms up behind his head and his left leg dangling from the bed. The officer could get no response from Mr Crockwell and summoned immediate assistance.

(18) Officer Martin responded within seconds. A medical emergency alert was issued and nursing staff attended within seconds of the call. Two doctors arrived shortly thereafter. Further nursing personnel arrived with resuscitative equipment. An ambulance was called.

(19) Mr Crockwell was placed on the floor of the cell and emergency cardiovascular resuscitation was commenced but to no effect. Mr Crockwell was already dead when he was discovered in his cell.

(20) Dr Chellamathu noted the time of death at 1155 am on 20 August 2008.

(21) A police surgeon attended who examined Mr Crockwell's body and formally pronounced life extinct at 1325 hours. Mr Crockwell's body was removed to the City Mortuary.

(22) On 22 August 2008, Dr Linda Iles and Dr Marjory Black, Consultant Forensic Pathologists at Glasgow University conducted a post-mortem examination on the body of Mr Crockwell.

(23) Initially, the cause of death was unascertained. Histological examination of heart tissue demonstrated a widespread and established infection to the heart muscle. The cause of death was certified as 1a. Myocarditis.

(24) Toxicological investigations revealed the presence of a moderate concentration of methadone and small amounts of benzodiazepines. Some acetone and a considerable amount of betahydroxybutyrate was detected. These were indicative of a significant metabolic disturbance, likely related to alcohol withdrawal and fatty change within the liver.

(25) Myocarditis renders the heart muscle susceptible to the generation of potential fatal cardiac arrhythmias and sudden death. It is a condition that gives rise to a wide range of symptoms, from minor aches and pains to severe cardiac compromise and breathing difficulties. Initially it is difficult to diagnose.

(26) Mr Crockwell had an established infection which was likely to have been present prior to his admission to Barlinnie. While he was in custody, he did not show any signs or symptoms of such an infection nor did he complain of feeling unwell.

 

 

FINDS AND DETERMINES

(1) In terms of Section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, that Colin Stein Crockwell, whose date of birth was 12 October 1971 died within Her Majesty's Prison, Barlinnie, Lee Avenue, Glasgow at 1325 hours on 20 August 2008 at which time he was a serving prisoner there;

(2) In terms of Section 6(1)(b) of the said Act, that the cause of his death was myocarditis;

(3) In terms of Section 6(1)(c) of the said Act, that there were no reasonable precautions whereby his death might have been avoided;

(4) In terms of Section 6(1)(d) of the said Act, that there were no defects in any system of working which contributed to his death; and

(5) In terms of Section 6(1)(e) of the said Act, that there were and are no further facts which are relevant to the circumstances of his death.

 

 

 

 

 

 

 

 

NOTE:

 

[1] This Fatal Accident Inquiry was convened to inquire into the circumstances of the death of Colin Stein Crockwell which occurred on 20 August 2008 within Her Majesty's Prison, Barlinnie, Glasgow ("Barlinnie"). He was 36 years of age having been born on 12 October 1971.

 

[2] The Inquiry proceeded under Section 1(1)(a)(ii) of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976 ("the Act") because at the time of his death Mr Crockwell was serving a sentence of imprisonment. A sentence of five months imprisonment had been imposed on 19 August 2008 at Glasgow Sheriff Court.

 

[3] At the Inquiry, Miss Greer, Procurator Fiscal Depute, appeared for the Crown in the public interest. Mrs Walkinshaw represented the Scottish Prison Service.

[4] I heard evidence from Miss Janet Crockwell, Mr Crockwell's sister. Staff from Barlinnie who gave evidence were Dr Buksh, medical officer, practitioner nurse Jeanette Marshall, Mrs Mary Mitchell, clinical manager, and prison officers Alan Gilmour and Stephen Martin. Constable Deryck Carruthers, Strathclyde Police and Dr Marjory Black, Consultant Forensic Pathologist, Glasgow University were also witnesses to the Inquiry. A joint minute of agreement of facts was tendered at the conclusion of the evidence.

 

[5] Members of Mr Crockwell's family, including his parents, were present during the Inquiry. In her evidence, Miss Janet Crockwell described her brother as a troubled and emotional man who had a long history of drug addiction and alcohol dependency. He suffered from depression and had previously self-harmed. From the witness-box, Miss Crockwell highlighted certain matters which were of concern to the family about the circumstances of Mr Crockwell's death. These concerns were put in the form of two questions:

·        Why had Mr Crockwell not been identified as someone who was vulnerable?

·        Why had he not been admitted to hospital?

 

[6] As to the first question, it was clear that the family had some concerns over the assessment made on admission that Mr Crockwell was not someone considered to be at risk of self-harm or in need of special measures of care. Notwithstanding these concerns, there was no question in this Inquiry that Mr Crockwell's death was other than the result of natural causes. Accordingly, the evidence concerning the assessment of Mr Crockwell's mental state insofar as it affected risk of suicide or self-harm was not directly relevant to the circumstances of his death. Therefore, these are not matters in connection with which it would be appropriate to include any findings in terms of the Act.

[7] As to the second concern expressed by the family, the circumstances of Mr Crockwell's medical care were explored in some detail. These can conveniently be considered under three headings: (1) the admission procedure; (2) the circumstances of his seizure; and (3) the cause of death.

 

Admission procedure

[8] Standard prison procedure requires every prisoner on arrival at Barlinnie to be processed in the reception area. The reception or admissions procedure involves three separate interview and assessment processes. The first involves interview by the reception officer. After that the prisoner is seen by a nurse. Finally, the prisoner is seen by a doctor. Depending on the time of the prisoner's arrival at the prison, he may or may not be seen by the doctor at that time. If he is not seen by the doctor at the admission stage, prison regulations require that he must be seen within 24 hours of arrival. In Barlinnie, prisoners who, like Mr Crockwell, arrive in the afternoon often do not see a doctor until the following day.

 

[9] The reception assessment takes the form of interviews during which certain questions are asked and answers are recorded. During this time the prisoner is observed. No direct evidence was led from any member of the prison staff who had carried out the admission procedures with Mr Crockwell but reference was made to the relevant documentation contained in the prison records which were produced at the Inquiry. These included the forms which were completed at the time of admission.

 

[10] From the nursing assessment form, it was clear that Mr Crockwell had disclosed that he was a heavy drinker and had problems with alcohol. He had also disclosed his drug addiction and informed the nurse that he took methadone, his prescription being 30 mls per day. He also advised the nurse that he suffered from epilepsy and was prescribed Epinin, an anti-convulsant drug.

 

[11] During the admission procedure, Mr Crockwell made no complaint of feeling unwell and gave no cause for concern. The comment "appears fine" was noted on the prison officer's assessment form. Mr Crockwell was allocated a cell on the fourth floor where prisoners routinely spend their first night.

[12] According to procedure, Mr Crockwell would have been due to see the doctor the following day to complete his admission process. Where a prisoner has not seen a doctor at the time of admission, his name is added to a list by the nurse. The list of prisoners who require to be seen by the doctor is taken to the Links Centre where clinics are held for that purpose. The prisoners' admission notes are attached to the list together with any previous prison records. Further, clinics are held the following morning and it is for residential officers to organise the attendance of prisoners. There is no particular order in which prisoners are seen but is a matter of liason and management between the Links staff and the residential staff and depends on other prison routines such as eating, showering, etc. No prisoner is afforded any particular priority. There was evidence from Mrs Mitchell that where a prisoner, like Mr Crockwell, had been seen by the nurse since admission, he would be seen at the end of the doctor's list. That was because he had already received his detoxification medication and had been seen by nursing staff and was being monitored by prison officers.

 

[13] At the time of his death, Mr Crockwell had yet to see the prison doctor for the third part of his admission assessment.

 

The circumstances of Mr Crockwell's seizure

[14] At approximately 6.30pm on the evening of his admission, in the course of a routine cell check, Mr Crockwell was seen to be having a fit. He was given immediate assistance by prisoner officers and nursing staff attended promptly. At that time, Dr Buksh was conducting admissions assessments for the evening arrivals. He answered an emergency call to Mr Crockwell's cell and arrived shortly after the nursing staff. On Dr Buksh's arrival, he noted that Mr Crockwell was no longer fitting. He was lying on the floor being attended to by nursing staff. He was conscious, responsive but confused. Nursing staff reported that his blood pressure had been recorded as 240/160 which was markedly high. However, Mr Crockwell made a good recovery from his seizure: within 10 to 15 minutes he was returning to his normal senses; his blood pressure had fallen to 140/100, which was the high side of normal; he was able to stand and then sit on a chair; his pulse was regular and normal showing a steady rhythm. He displayed no other symptoms which caused concern.

 

[15] Dr Buksh diagnosed an alcohol-related seizure precipitated by alcohol withdrawal, a diagnosis with which the pathologist agreed. He commenced Mr Crockwell on an alcohol detoxification regime and prescribed chlordiazepoxide, otherwise known as Librium. Mr Crockwell was administered his first dose of 40 milligrammes at 7.25 pm that evening. Librium is a tranquillizer type drug which acts in a number of ways. In prescribing it Dr Buksh intended that it would relax Mr Crockwell, reduce any cravings he had for alcohol, prevent delirium tremens and, significantly, prevent further seizures. Dr Buksh instructed that Mr Crockwell be reviewed the following day and that full blood tests should be carried out to establish the levels of Epilin (the anti-convulsant prescribed by his general practitioner). Dr Buksh remained with Mr Crockwell and observed him until he was satisfied that Mr Crockwell had recovered.

 

[16] In light of Mr Crockwell's rapid recovery from his seizure, Dr Buksh did not consider that any further medical intervention was necessary. There was evidence from Mrs Mitchell that a number of prisoners suffer from epilepsy or seizures and are on anti-convulsant medication. Staff are experienced in managing them within the prison setting.

 

[17] Following Mr Crockwell's seizure, certain further steps were taken to ensure his safety and well-being. First, Mr Crockwell was moved from his cell on the fourth floor to one on the ground floor (cell 1/7). This ensured easy access by nursing and medical staff in the event of a further medical problem and was designed to increase his safety. Prisoners with medical conditions are often housed on the ground floor flat for easier and safer management. Mr Crockwell's medical notes and admission records were kept with him on the ground floor should access have been required during the night in the event of a further emergency. Nursing staff are on duty 24 hours a day in the prison. There is a doctor on the premises from 8am to 8pm and a duty doctor on call for emergencies outwith these hours.

 

[18] Secondly, nursing staff raised a medical marker in respect of Mr Crockwell's condition. This highlighted the fact that he had suffered a seizure and alerted the residential officers on the ground floor flat to be vigilant for signs and symptoms indicative of any further seizure. Accordingly, staff were fully informed of Mr Crockwell's condition.

 

[19] Thirdly, Mr Crockwell was placed on strict medical observation. This required officers to check him by means of visual observation at hourly intervals. These observations were carried out throughout the night without incident. No concerns were noted. At no time did Mr Crockwell make any complaint of feeling unwell.

 

Cause of death

[20] The following morning at about 7.30 am, Mr Crockwell was escorted the short distance to the nursing station so that he could receive his medication. Nurse Janette Marshall was on duty. She conversed briefly with Mr Crockwell to the extent of asking him to give him his name and prison number for identification purposes. He provided these details without difficulty. He was given his second dose of Librium and nothing of concern was noted about his presentation or condition. Had Nurse Marshall had any concerns she would have acted upon these there and then by taking a full set of observations and, if necessary, arranging for him to be seen by a doctor immediately. Prison officer Gilmore escorted Mr Crockwell back to his cell. Although Mr Crockwell made no complaint of feeling unwell, Mr Gilmore described him as looking "a bit rough, as if he had a hangover". He re-assured Mr Crockwell that his medication would soon take effect and he would feel better. Mr Crockwell refused the offer of breakfast.

 

[21] Further observations were carried out on Mr Crockwell at 9.10am and 10.20am. His condition did not give any cause for concern. However, at 11.40 am, prior to going off duty, officer Gilmore went into Mr Crockwell's cell. He immediately noticed that something was wrong: Mr Crockwell was lying on his bed on his back with his arms behind his head. One of his legs was dangling off the bed. Officer Gilmore was unable to get a response from Mr Crockwell and immediately called for assistance. Prison officer Steven Martin attended at once and on seeing Mr Crockwell's pallor he, too, knew that something was wrong. He put out a "Code Blue" emergency call. This alarm is raised when the emergency involves a respiratory problem. Nurse Marshall was a few yards away at the medication desk and attended in a matter of seconds. She noted that Mr Crockwell's face was ashen and that he was cold to the touch. She formed the impression that he was already dead.

 

[22] Emergency call buttons are located in each cell in the event that a prisoner requires urgent assistance. At no time had the emergency buzzer located within Mr Crockwell's cell been activated.

[23] Two doctors arrived within minutes of the alert and other nursing personnel attended with resuscitation equipment. Emergency CPR was commenced and continued for sometime but to no avail. Dr Chellamathu, one of the doctors in attendance, noted the time of death at 1155 on 20 August 2008. Officers from Strathclyde Police attended, noted statements and arranged for Mr Crockwell's body to be removed to the City Mortuary for autopsy examination. A police casualty surgeon arrived and formally pronounced life extinct at 1325 hours which is the time noted on the death certificate.

 

[24] A post-mortem examination carried on 22 August 2008 did not immediately reveal a cause of death. However, subsequent histological examination of heart tissue disclosed an extensive infection of the heart muscle: a condition known as myocarditis. The sample showed a diffuse widespread infiltrate of inflammatory cells indicating an established myocarditis, being an inflammatory condition of the heart muscle. According to Dr Black, many things can cause myocarditis. It may be caused by infection - most often viral infection, including the common cold virus. It may result from an autoimmune reaction or it may be an allergic reaction to drugs. In Mr Blackwell's histology, there were some features suggestive of a drug related myocarditis as a result of an allergic response. Dr Black explained that large numbers of drugs can cause this condition, including some anti-convulsant drugs although the drug Epilim was implicated less frequently than other anti-convulsants.

 

[25] Myocarditis can cause a wide range of symptoms which can vary from almost none to full- blown heart failure. However, often a person will have a fever or chill indicating a temperature. Chest pain and difficulty breathing are other symptoms. Dr Buksh's evidence was that myocarditis is very difficult to diagnose and is usually only confirmed after certain further investigations had been undertaken, such as blood tests and an electrocardiogram. He would expect to see symptoms such as signs of tachycardia (a fast heart beat), fever, aches and pains and vomiting and nausea. He would expect a patient with myocarditis to be feeling unwell. Mr Crockwell showed none of these symptoms. On the contrary, his pulse was 85 which was within normal limits and his heart beat was steady and regular.

 

[26] Myocarditis renders the heart muscle susceptible to the generation of potentially fatal cardiac arrhythmias and sudden death as, in Dr Black's opinion, had occurred in Mr Crockwell's case. The significance of acute alcohol withdrawal and the extent to which that played a part in his death was, in her opinion, not clear. Toxicological studies demonstrated a small amount of acetone and a considerable amount of betahydroxybutyrate. These substances were signs of a significant metabolic disturbance, most likely related to alcohol withdrawal and fatty change within the liver. In Dr Black's opinion, it was possible that the stress of acute alcohol withdrawal decreased the threshold at which cardiac arrhythmias may occur.

 

[27] From the evidence of Dr Black and Dr Buksh, it was clear that Mr Crockwell had a condition that made him liable to sudden death at any time. He had not shown any symptoms of this condition nor had he complained of feeling unwell at any time. Mr Crockwell could have had the condition for some time. It was Dr Black's opinion that it was likely that the condition had been present longer than a few hours and so likely that Mr Crockwell had the condition before he was admitted to prison. His was a widespread and established infection.

 

[28] Dr Black was clear in her opinion that in the absence of symptoms or any complaints, the condition was not likely to have been diagnosed in the course of a routine medical examination. Therefore, even had Mr Crockwell been seen by a doctor for the purposes of completion of the admission assessment, it is highly unlikely that this would have altered the course of events and prevented his death.

 

[29] The seizure from which Mr Crockwell had recovered and as a result of which he remained under observation was, in the opinion of Dr Black, unrelated to the cause of his death.

 

[30] It was Dr Black's opinion that in all the circumstances Mr Crockwell's death could not have been prevented.

 

Conclusions

[31] Having regard to the evidence, I was satisfied that Mr Crockwell received prompt and appropriate medical treatment in connection with the seizure he suffered on the evening of his admission and that proper steps were taken to monitor his condition thereafter. He did not suffer a further seizure and the single episode was unrelated to his death.

 

[32] In the absence of symptoms of infection and any complaints of feeling unwell, the infection in Mr Crockwell's heart muscle remained undetected. It was very likely that this myocarditis was a pre-existing condition and it was one which rendered him liable to collapse and sudden death at any time. In the circumstances, Mr Crockwell's death could neither have been predicted nor prevented during the short time between his admission to Barlinnie and his death.

 

[34] Understandably, Mr Crockwell's family believed that had he been admitted to hospital after his seizure, or had he been seen by the prison doctor earlier in the morning then he might not have died. From the evidence in the Inquiry, there was no suggestion that Mr Crockwell required hospitalisation on account of his seizure. Many prisoners with epilepsy are managed within the prison setting. As far as his epilepsy was concerned, Mr Crockwell was looked after appropriately and steps were taken to ensure that officers were made aware of his condition and the requisite medical marker was raised. He remained under special observation. In the event, the epilepsy was not related to the cause of his death. As to the matter of what might have happened had he been seen by a doctor for routine admissions examination, the clear evidence was that it was highly unlikely that the myocarditis would have been diagnosed or, indeed, that anything could have been done to prevent his death.

 

[35 ] At the conclusion of the Inquiry, the Crown invited me to make a Determination that was formal in its terms. Mrs Walkinshaw, on behalf of the Scottish Prison Service, did likewise. In light of the evidence and the submissions thereon, I am satisfied that I can make a Determination under Section 6(1)(a) and 6(1)(b). There are no circumstances which would justify any further findings.