Evening Telegraph (First Edition)
Prison death ruled
Breakdown between jail health team and hospital
Scott Ross died in his cell.
A BREAKDOWN in communication between Perth Prison’s health team and the local hospital may have contributed to the death of a remand inmate from Dundee.
Scott Ross, 37, of Court Street North, died in his cell at HMP Perth early on June 21 2018. He had been on remand for a week facing drug misuse and culpable and reckless conduct charges.
A fatal accident inquiry at Perth Sheriff Court found the cause of death was probable drug-withdrawal seizures.
The inquiry heard he had been taken from the prison to Perth Royal Infirmary (PRI) several times after having seizures.
PRI staff deemed the seizures “behavioural” and failed to recognise they were symptomatic of his drug withdrawal.
The hospital had been treating him as if he were withdrawing from opiates when he was actually coming off benzodiazepine – Valium or similar
The judgment by Sheriff William Wood after the FAI into Mr Ross’s death found it could have been avoided had other steps been taken.
The inquiry heard on arrival in prison on June 14, Mr Ross told staff he had been – daily – snorting 1.5g of heroin and taking between 40 and 50 Valium tablets, as well as methadone and pregabalin.
On the morning of June 16 2018, Mr Ross had a 10-minute seizure followed by a second in the afternoon, after which he was moved to an observation cell, where he had another.
Mr Ross was taken by ambulance to PRI, where a doctor told him his seizures were due to “going cold turkey from heroin.”
On the journey back to prison on June 17, Mr Ross was sick and may have had a seizure.
At 4pm that day, he had another seizure – dismissed as “behavioural” by the doctor after the prison nurse contacted PRI.
He was taken back to hospital at 5.30pm and next day, was recorded as having “seizure-like activity”.
Sheriff Wood noted he was also recorded as having “heavy breathing, pretending to have a fit but doctors are not believing him”.
Mr Ross refused to co-operate with his discharge, “faked a fit” and had to be carried on to the prison van.
On his return to jail, he was unable to speak or respond to simple commands.
He was later found lying on the floor of the cell in a state of “stupor” and while staff phoned PRI again, Mr Ross had another seizure. He was brought to
PRI’s high-dependency unit and intubated.
He was due to be discharged again the following day, June 19, but had a fit on the floor when prisoner transport arrived.
Staff said he remained fit to be discharged.
Overnight in jail, Mr Ross was subject to half-hourly checks but found unresponsive at dawn and declared dead after resuscitation attempts. A postmortem examination stated the cause of death was established as “probable drug-withdrawal seizures”.
It was established the prison health team had used a different assessment method to that of the hospital.
Sheriff Wood wrote in his judgment: “(Upon arrival in prison) he was prescribed a “standard detox”. Between June 16 2018 and June 18 2018, Mr Ross was admitted to Perth Royal Infirmary on three occasions. PRI carried out their own assessment, in accordance with their protocols, which differed from the prison.
“The hospital was not aware of the prison protocol or the terms of the “standard detox” prescribed; and their own assessment did not indicate that diazepam medication was necessary.”
He found the death could have “realistically been avoided” if Mr Ross had been prescribed treatment and that had been increased in the event of further seizures, if PRI had provided a realistic detoxification plan to keep him safe and if the detox plan had been consistent.
The inquiry also found Mr Ross
should have been readmitted to hospital the day before he died.
The FAI found “standard detox” protocol used by prison healthcare staff did not take into account pre-existing levels of abuse and may not be adequate in every case.
It found Mr Ross did not receive enough benzodiazepines to prevent seizures and death.
Sheriff Wood said: “The death of Scott Ross was unusual, although it has laid bare the possible consequences of inadequate communication between one branch of health care and another.”
“It may well be a rare occurrence that there are fatal consequences from the failure to communicate effectively and timeously but that does not mean that there are no faults in the system.”