INQUIRY UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF JAMES ALEXANDER CAMPBELL
2015FAI23
SHERIFFDOM OF NORTH STRATHCLYDE AT GREENOCK
B74/15
DETERMINATION OF Sheriff DEREK J HAMILTON, ESQ
in respect of
the Fatal Accident Inquiry into the death of
JAMES ALEXANDER CAMPBELL
(Born 14 January 1953)
under the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976
GREENOCK: 15 September 2015
This inquiry was a mandatory inquiry in terms of section 1 of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 ('the Act'), into the circumstances of the death of James Alexander Campbell, who died at Inverclyde Royal Hospital, Greenock on 11 August 2013.
The Sheriff, having considered all the evidence and submissions heard on 14 and 15 September 2015, FINDS and DETERMINES in terms of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976 as follows –
(1) In terms of Section 6(1)(a) of the Act, that James Alexander Campbell, born 14 January 1953, a prisoner at HM Prison, Gateside, Greenock died at Inverclyde Royal Hospital, Greenock on 11 August 2013, at 16.20 hours.
(2) In terms of Section 6(1)(b) of the Act, that the cause of James Alexander Campbell’s death was,
(i) Multiple organ failure,
due to,
(ii) Liver cirrhosis with disseminated hepatocellular carcinoma,
due to,
(iii) Hepatitis C infection.
(3) In terms of Section 6(1)(c) of the Act, that there were no reasonable precautions whereby the death of James Alexander Campbell might have been avoided. There is no criticism of the Scottish Prison Service or of the National Health Service,
(4) In terms of Section 6(1)(d) of the Act, that there were no defects in the system of working which contributed to the death of James Alexander Campbell.
NOTE
[1] The inquiry heard evidence and submissions on 14 and 15 September 2015.
At this Inquiry, parties were ably represented as follows:
- The Lord Advocate: Ms McBride, Procurator Fiscal Depute
- Scottish Prison Service:Ms Burke
- Greater Glasgow Health BoardMr O’Reilly
[2] The family of Mr Campbell was not represented, although Mr Campbell’s cousin, Margaret Coyle, and Mr Campbell’s former solicitor, Ms Anita Bromley, were present during the first day of the hearing.
[3] The Crown initially led evidence from three witnesses: (1) Gordon Hannah, Health Care Manager, HM Prison, Gateside, Greenock, (2) Dr Janet Graham, Consultant Medical Oncologist, c/o Beatson West of Scotland Cancer Centre, Gartnavel General Hospital, Glasgow and (3) Dr Mathis Heydmann, Consultant Gastroenterologist and Hepatologist, c/o Royal Alexandra Hospital, Paisley. There was no cross examination of any of these witnesses.
[4] A joint minute of agreement of evidence was signed by all three solicitors and lodged. No other evidence was led on the first day.
[5] On the second day, the Crown offered to lead a further witness to assist the enquiry, Jacqueline Tomnay, nurse, c/o Crosshouse Hospital, Kilmarnock. Mr O’Reilly and Ms Burke agreed that the witness might be of assistance and I therefore heard evidence from Ms Tomnay.
[6] The procurator fiscal depute asked that the court make findings in terms of sections 6(1)(a) and 6(1)(b) of the Act, and to make no findings in respect of sections 6(1)(c), 6(1)(d) and 6(1)(e) of the Act. Those submissions were adopted by the Scottish Prison Service and by the National Health Service, and I have followed the terms of the submissions in my findings.
[7] On 20 March 1997 at Norwich Crown Court, Mr Campbell was sentenced to a term of life imprisonment. He was transferred through a number of prisons, eventually to HM Prison Gateside, Greenock in April 2012.
[8] Whilst in prison, Mr. Campbell contracted Hepatitis C. That was believed to be around 1997. The date of diagnosis and of any treatment is not known with any certainty, as Mr. Campbell’s prison health records during his time in England were not made available to the enquiry, despite the efforts of the Crown.
[9] Records from 2003 for Mr Campbell indicated that at that time he did not have moderate or severe liver disease. He was not treated and was subject to annual reviews. Prior to 2006 treatment for Hepatitis C was given to only those who had moderate or severe liver disease. Following a Scottish Government action plan in 2006, treatment was offered to all Hepatitis C carriers. Mr. Campbell received treatment for Hepatitis C in 2009 whilst in HM Prison, Glenochil. That treatment was unsuccessful and Mr. Campbell relapsed. Mr Campbell underwent further investigations from 2012 when he was transferred to HM Prison, Gateside, Greenock, and he underwent a second, longer, course of treatment.
[10] Whilst at HM Prison, Gateside, Greenock, initial investigations and scans indicated that another particular course of treatment of the liver might be appropriate for Mr Campbell. Unfortunately later scans taken just before that particular treatment was to commence showed that Mr Campbell had extensive cancer in his liver and in secondary areas within his body. Hepatitis C in the liver creates a high risk of cancer developing in the liver, and that was the position for Mr Campbell. It was concluded that there was no effective treatment of the cancer. Mr Campbell therefore received palliative treatment, and treatment for Hepatitis C.
[11] There was a sudden decline in Mr Campbell’s health due to the cancer spreading and Mr. Campbell was admitted to Inverclyde Royal Infirmary for treatment on 9 August 2013. Treatment could not commence immediately, and Mr Campbell elected to discharge himself from the hospital over that weekend so that he could spend more time with his family. When he returned to hospital on 11 August 2013, Mr Campbell was very poorly, and he succumbed to his illness on that day.
[12] I heard evidence about significant advances in the effective treatment of Hepatitis C. Sadly, such advances appear to have been very much too late for Mr Campbell who, it would seem, had Hepatitis C from around 1997.
[13] I wish to thank the witnesses for their assistance with this inquiry, and in particular I would like to thank Ms Tomnay for attending at short notice. Her evidence was invaluable in describing the changing landscape of Hepatitis C treatment and its success.
I would also like to thank the procurator fiscal and the solicitors who appeared. Much evidence was agreed in a joint minute, and this reduced substantially the oral evidence that required to be heard.
[14] Finally, I would wish to record my condolences to Mr Campbell’s family, and in particular to Ms Coyle who attended the hearing.
Sheriff Derek J. Hamilton
Sheriff of North Strathclyde