Recommendations for NHS Forth Valley following Fatal Accident Inquiry into death of prisoner

Peter Carter, 53, who was a prisoner at HMP Glenochil, died on June 11, 2019 after being transferred to Forth Valley Royal Hospital and undergoing surgery.

He had been a patient at the hospital from May 23, 2019, receiving treatment for suspected cholecystitis and was discharged on June 4.

On June 10, blood tests were taken by NHS Forth Valley nursing staff at Glenochil to be analysed at FVRH’s laboratory. The results did not meet a pre-determined ‘set criteria’ and were not communicated to medical staff at the prison.

The following day, Carter was examined again by nursing staff within the prison, the blood test results were accessed and an ambulance was summoned. That same day he underwent surgery at the hospital and later died from complications of an ischaemic bowel.

Carter was serving an extended sentence comprising nine years imprisonment with a three year extension period, which was imposed in May 2015.

Following a Fatal Accident Inquiry (FAI), Sheriff Neil Bowie found there were ‘reasonable precautions’ that could have been taken which may have realistically resulted in Carter’s death being avoided.

The sheriff found that precautions that could have been taken included not discharging Mr Carter from hospital on June 4 and him remaining in hospital for further review; as well as his blood test results on June 10 being immediately reported to the requesting clinician.

Defects were noted in Forth Valley Royal Hospital’s laboratory system relating to clinical oversight/ review of patient blood tests by clinical scientists between May 23, 2019 and June 11, 2019.

The sheriff’s determination said the system was “defective”.

The system in reporting of patient blood test results to requesting clinicians between May 23 and June 11, 2019 was defective in that the set criteria relating to ‘new findings’ did not account for changes in patient’s circumstances.

The system was also found not to provide any alert to clinicians when results are generated leading to the results on June 4 remaining unchecked. Had they been known, it is reasonable to suggest that his discharge would have been delayed.

The sheriff made four recommendations to the health board in his determination in relation to reviews of clinical oversight of laboratory test results and the discharge process of patients to a prison setting.

He also identified defective systems within the hospital’s laboratories which contributed to his death.

A spokesperson for NHS Forth Valley said: “We fully accept the report recommendations and have already made a number of changes to our laboratory and discharge arrangements to address the issues highlighted.

“Further work is also underway to ensure that all of the recommendations are met within the required timescales.”

The mandatory Fatal Accident Inquiry was held as Carter died while in legal custody and in the care of the state.