INQUIRY INTO THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF KENNETH WILLIAM DUTCH
SHERIFFDOM OF NORTH STRATHCLYDE AT GREENOCK
[2015] FAI 34
DETERMINATION
BY SHERIFF THOMAS WARD, ESQ
UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRIES (SCOTLAND) ACT 1976
into the death of
KENNETH WILLIAM DUTCH
(born 17 July 1962)
Greenock 18 November 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 surrounding the death of Kenneth William Dutch, who died in HM Prison, Greenock, on 11 February 2014.
The Sheriff, having considered all of the evidence and submissions heard on 18 November 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 Kenneth William Dutch, born 17 July 1962, a prisoner at HM Prison, Gateside, Greenock, died at HM Prison, Gateside, Greenock, on 11 February 2014 at 2005 hours.
2. In terms of Section 6(1)(b) of the said Act, that the cause of Kenneth William Dutch’s death was:
(i) (a) coronary artery atheroma.
3. In terms of Section 6(1)© of the said Act, that there were no reasonable precautions whereby the death of Kenneth William Dutch might have been avoided.
4. In terms of Section 6(1)(d) of the said Act, that there were no defects in the system of working which contributed to the death of Kenneth William Dutch.
5. In terms of Section 6(1)(e) of the said Act, that there were no other facts which are relevant to the circumstances of the death.
NOTE
[1] The Inquiry heard evidence and submissions on 18 November 2015. At the Inquiry, Ms Dodds, Procurator Fiscal Depute, appeared on behalf of the Crown and Ms Phillips, Solicitor, appeared on behalf of the Scottish Prison Service. There were no other representatives.
[2] The Crown led two witnesses, namely Dr Dominique Van Den Meersschaut, and Dr Leah McAleer. Dr Meersschaut was employed by the Prison Service and Dr McAleer at the relevant time was a General Practitioner.
[3] A Joint Minute of Agreement was signed by Ms Dodds and Ms Phillips. That Joint Minute narrated that Kenneth William Dutch was in HM Prison, Gateside, Greenock, serving a life sentence for murder and gave a brief resume of his medical condition prior to his death. It also narrated the circumstances surrounding his death.
[4] The Procurator Fiscal Depute asked me to make findings in terms of Section 6(1) (a) and 6(1)(b) of the said Act and to make no findings in respect of Section 6(1)(c), 6(1)(d) and 6(1)(e). Those submissions were adopted by Ms Phillips on behalf of the Scottish Prison Service.
[5] On 25 May 1979, at the High Court in Dundee, Kenneth William Dutch was sentenced to life imprisonment for murder.
[6] Kenneth William Dutch moved through various prisons in the prison system until 9 August 2013 when he was moved from HM Prison, Edinburgh, to HM Prison, Greenock. He was in legal custody until the date of his death on 11 February 2014.
[7] In 2011, whilst an inmate at HM Prison, Shotts, Kenneth William Dutch was seen by the Keep Well Team on several occasions for proactive well-man checks, including blood pressure monitoring, smoking cessation, lipid monitoring and general health advice. Because Kenneth William Dutch’s family had a strong family history of ischemic heart disease, the prison doctor referred him to the Cardiology Department at the Edinburgh Royal Infirmary.
[8] On 22 January 2012, whilst an inmate within HM Prison, Saughton, Kenneth William Dutch was reviewed by a Consultant Cardiologist at the Royal Infirmary, Edinburgh. At this time, it was noted that Kenneth William Dutch had been experiencing a two-year history of very atypical chest pain, described as sharp and shooting in nature. All of the tests done on the deceased were normal. He was reassured that he had atypical non-cardiac chest pain and the importance of ceasing to smoke was reiterated to him.
[9] Dr Van Den Meersschaut saw Kenneth William Dutch on 11 December 2013, when he complained of stomach pain. He had undergone surgery for a hernia only a few weeks earlier and Dr Van Den Meersschaut told him that the pain he was experiencing was simply part of the recovery process. He did not require any medication.
[10] Kenneth William Dutch was seen by Dr Leah McAleer on 4 February 2014. He was seen under the auspices of the Keep Well Scheme. It was noted that his cholesterol level was high. His cardio-vascular risk was discussed with him. He was told he was at high risk because of his age, his high cholesterol level and the fact that he was still a smoker. Statins were discussed and it was agreed to place him on a regime of statins. He was also on a smoking cessation therapy scheme. He was told to keep in contact with the doctor if there were any further problems. He was not medically unwell when Dr McAleer saw him.
[11] On 10 February 2014, Kenneth William Dutch was seen by the prison nurse, complaining of nausea following commencement of the statin medication. The statin medication was stopped and an appointment was arranged for him to be seen on 13 February 2014.
[12] On 11 February 2014, at 7.30 pm, Kenneth William Dutch was within Chriswell House, Staff Office, Greenock, talking with a member of prison staff. He suddenly complained of feeling dizzy, had a seizure, collapsed and fell unconscious.
[13] Medical assistance was immediately summoned. Two practitioner nurses arrived almost immediately. Kenneth William Dutch’s pulse could be felt, but was thready and rapid. After about thirty seconds, his pulse became unobtainable. He then cyanosed quite rapidly. An emergency ambulance was ordered. CPR was performed on the deceased. In addition, Yvonne Munro commenced oxygen therapy. The deceased’s blood pressure was unobtainable and his oxygen saturation was 74 per cent. His airways were clear but he did not respond to the efforts to revive him. After approximately three minutes, defibrillation was attempted. He was given two shocks but there was no response to either. CPR and oxygen therapy was continued until paramedics arrived at 1945 hours.
[14] On arrival, the paramedics continued with revival procedures, without success, and life was pronounced extinct at 2005 hours on 11 February 2014.
[15] A post-mortem examination was carried out on the deceased on 17 February 2014 at the Southern General Hospital, Glasgow, by Consultant Pathologist, Marjory Turner. The cause of death was (i) (a) coronary artery atheroma. The post-mortem examination concluded that the deceased could have died suddenly from a cardiac arrhythmia at any time, which would account for his symptoms and his death. There was no evidence of any other significant natural disease. There were no significant injuries. Toxicology revealed only a therapeutic level of his prescribed Tramadol. Death was due to natural causes.
THOMAS WARD
Sheriff of North Strathclyde at Greenock