2012 FAI 13
DETERMINATION
In terms of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 by Sheriff Robert H Dickson, following an Inquiry held at Cumbernauld between 24th October and 16th November into the death of Mr Andrew Ritchie
Airdrie 16th February 2012
The inquiry into the death of Mr Andrew Ritchie was held at Cumbernauld between 24th October and 16th November 2011. At the same time I was asked to consider evidence in relation to the deaths of Mrs Agnes Nicol and Mr George Johnstone.
The Procurator Fiscal at Airdrie on behalf of the Lord Advocate had on 23rd November 2010 petitioned the Court to hold this joint inquiry in terms of Section 1(1)(b) of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976. It was (correctly) considered to be expedient in the public interest to hold an inquiry into three deaths which had occurred in a three month period in 2006 following in each case a laparoscopic cholecystectomy in a Lanarkshire hospital.
The evidence revealed a number of common features in the circ*mstances of two or even all three deaths. It also showed in each case factors which were unique to that particular tragedy.
In the circ*mstances I have therefore decided to issue a separate determination in relation to each death recording the relevant findings and highlighting, where appropriate, any features which overlap in relation to either or both of the other deaths. I consider that the relatives of Mr Ritchie are entitled to know that I have given separate consideration to the death of their loved one and have separately recorded the particular circ*mstances surrounding it.
The Lord Advocate was represented by Mrs Anne Ferguson, Senior Depute Procurator Fiscal at Airdrie.
The family of Mrs Agnes Nicol listened to the evidence as did the family of Mr George Johnstone and Mr Andrew Ritchie. None had legal representation. Miss Morag Nicol (daughter) spoke on behalf of her mother's relatives, Mrs Alice Johnstone, Mr Johnstone's widow and Mr William Ritchie, a cousin of Andrew Ritchie also asked questions of witnesses and all made submissions at the conclusion of the evidence.
Mrs Laura Donald, solicitor, appeared on behalf of witness numbers 2 and 11, Mr Duncan Mawby, solicitor, represented witnesses numbers 4, 9 and 16 while Lanarkshire NHS Trust were represented by Mr Douglas Ross, Advocate, instructed by the Central Legal Office, Edinburgh.
A joint minute of admissions agreeing the terms of production 35 was lodged.
I heard evidence from:-
(1) Dr Ahmed Ali, Senior House Officer, Wishaw General Hospital.
(2) Mr John Cannon, Consultant Surgeon, Wishaw General Hospital.
(3) Dr Lal Singh, Surgeon, Wishaw General Hospital.
(4) Mr Hakim Ben Younes, Consultant Surgeon, Wishaw General Hospital.
(5) Dr Donald McLean, Consultant Anaesthetist, Wishaw General Hospital.
(6) Dr Alan Morrison, Consultant Anaesthetist, Wishaw General Hospital.
(7) Dr Alison Simpson, Consultant Anaesthetist, Wishaw General Hospital.
(8) Mrs Alice Johnstone
(9) Mr Joseph Cumming, Consultant Surgeon, Monklands District General Hospital, Airdrie.
(10) Dr Jolene Wotherspoon, Senior Surgical House Officer, Monklands District General Hospital.
(11) Mr Myklos Kassai, Consultant Surgeon, Monklands District General Hospital.
(12) Dr Alistair McGee, Consultant Radiologist, Monklands District General Hospital.
(13) Dr Scott Marshall, Consultant Anaesthetist, Monklands District General Hospital.
(14) Dr Ruth Rae, Consultant Anaesthetist, Monklands District General Hospital.
(15) Andrew Burnett, HECT Nurse, Monklands District General Hospital.
(16) Mrs Alison Lannigan, Consultant Surgeon, Wishaw General Hospital.
(17) Dr Robert Ainsworth, Consultant Forensic Pathologist, University of Glasgow.
(18) Dr Marjorie Turner, Consultant Forensic Pathologist, University of Glasgow.
(19) Dr Julie McAdam, Consultant Forensic Pathologist, University of Glasgow.
(20) Professor O James Garden, Department of Clinical and Surgical Sciences, Royal Infirmary, Edinburgh.
(21) Professor John Kinsella, Consultant Anaesthetist, Glasgow Royal Infirmary.
(22) Dr Jane Burns, Assistant Divisional Medical Director, Monklands, Wishaw and Hairmyres Hospitals, Hairmyres Hospital, East Kilbride.
(23) Dr Gordon Dewar, Consultant Anaesthetist, Monklands District General Hospital.
The posts referred to in this list record the positions held by the witnesses in 2005/2006.
Since that time Mr John Cannon and Dr Lal Singh have retired. Dr Wotherspoon now holds a position as a surgical registrar in Wales and Dr Kinsella was appointed Professor and head of the academic unit of anaesthesia, pain and critical care at the University of Glasgow in 2007. Dr Jane Burns has since August 2010 held the position of Divisional Medical Director for Lanarkshire NHS Trust. Dr Gordon dewar now holds the post of a Consultant at the new Forth Valley Hospital at Larbert.
The following productions were referred to in the course of the inquiry:-
(1) GP records (Agnes Nicol).
(2) Wishaw General Hospital Records (Agnes Nicol).
(3) Typed operation note re Agnes Nicol (by Mr John Cannon dated 22nd December 2005).
(4) - (6) Edinburgh Royal Infirmary Records (Agnes Nicol).
(7) Typed operation note re Agnes Nicol (by Professor O James Garden dated 31 December 2005).
(8) Post Mortem Report dated 28th March 2006 re Agnes Nicol by Dr Robert Ainsworth.
(9) Expert Report dated 19th March 2007 re Agnes Nicol by Professor O James Garden.
(10) Additional Expert Report dated 10th October 2008 re Agnes Nicol by Professor O James Garden.
(11) GP Records (George Johnstone).
(12) Monklands District General Hospital Records (George Johnstone).
(13) Typed operation note re George Johnstone (by Mr Joseph Cumming dated 9th May 2006).
(14) Post Mortem Report dated 21 June 2006 re George Johnstone by Dr Marjorie Black.
(15) Expert Report dated 12th January 2007 re George Johnstone by Professor O James Garden.
(16) Additional Expert Report dated 10th October 2008 re George Johnstone by Professor O James Garden.
(18) Wishaw General Hospital Records (Andrew Ritchie).
(19) Typed operation note dated 14th June 2006 re Andrew Ritchie by Ms Alison Lannigan.
(20) Post Mortem Report dated 2 August 2006 re Andrew Ritchie by Dr Julie McAdam.
(21) Report by Ms Alison Lannigan re Andrew Ritchie.
(22) Expert Report dated 29th January 2007 re Andrew Ritchie by Professor O James Garden.
(23) Supplementary Expert Report dated 12th November 2007 re Andrew Ritchie by Professor O James Garden.
(24) Supplementary Expert Report dated 10th October 2008 re Andrew Ritchie by Professor O James Garden.
(25) to (34) - Clinical papers referred to by Professor Garden in his reports.
(35) Report dated 18th January 2011 by Colin J McKay, Consultant Pancreaticobiliary Surgeon.
(36) Report by Professor John Kinsella.
(37) Letter dated 28th December 2005 by Mr John Cannon re Agnes Nicol.
(38) Undated medical report by Mr John Cumming re Mr George Johnstone.
(39) 1-11 X-ray and image reports re Mr George Johnstone.
(40) Photographs (seven) illustrating gall bladder and relative arteries, veins and ducts.
(41) Supplementary report dated 12th November 2007 re George Johnstone by Professor O James Garden.
(1) Andrew Ritchie who resided at Flat 61 Burnside Tower, Motherwell died at 3:00pm on 23 June 2006 within Wishaw General Hospital. He was aged 62 and although he had a number of health problems none were life threatening.
(2) On 24 January 2006 Mr Ritchie was taken to the hospital by ambulance as an emergency having been referred by his General Practitioner, Dr John Lando. He was complaining of acute abdominal pain in the right upper quadrant (RUQ) and a preliminary diagnosis of cholecystitis was made.
(3) He was admitted to the emergency receiving unit and remained overnight. On examination he was found to be jaundiced and suffering from RUQ pain and that both had persisted for three weeks. The pain had increased in the few days before his admission to hospital. His urine was darker than usual.
(4) An ultrasound was carried out on 25 January which showed that the gallbladder was "grossly abnormal". It was distended, the walls were thickened and inflamed and the inflammation extended into the surrounding tissue.
(5) At the time of his admission Mr Ritchie came under the care of Mrs Alison Lannigan, a Consultant General Surgeon who was the duty surgeon for emergency admissions that day. Mrs Lannigan had been the consultant surgeon for five years. At that time, (the policy has changed since), the general surgeons worked on a rota, each taking a turn to be responsible for emergency admissions. In 2005/06 once a patient had come under the care of a particular general surgeon following an emergency admission, that patient remained under the care of the same surgeon. Accordingly from 24 January 2006 until his death Mr Ritchie was under the care of Mrs Lannigan. Mrs Lannigan saw and examined Mr Ritchie on 24 January and recorded her findings in the medical records.
(6) Mr Ritchie was treated conservatively and responded to the care and antibiotic medication to the extent that the readings for his white cell count (WCC) and liver function test (LFT) returned to the normal range and his Creative protein level (CRP), (an indication of inflammation as is the raised white cell count), was reduced from 184 to 48. His bilirubin readings reflected his improved health. He was allowed to leave the hospital on 2 February and he returned for an outpatient appointment on 3 March. During his stay in the hospital Mrs Lannigan had rejected the possibility of removing Mr Ritchie's gallbladder at that stage. She did so because he had been fairly septic and required antibiotics. There was no evidence of the presence of stones or problems with the bile duct which might have necessitated a non-elective operation.
(7) On 3 March Mr Ritchie was seen by Dr Dayal, a Senior House Officer attached to the Breast team of which Mrs Lannigan was the...
