Scottish Sheriff Court Decisions

GLASGOW, 25 February 2002.

The Sheriff Principal, having considered all the evidence adduced, DETERMINES: in terms of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976 Section 6(1) (a) that JOANNE HARKINS, aged 26 years who resided at 221 Allison Street, Glasgow, died at the Victoria Infirmary, Glasgow at 02.40 hours on 7 May 2000;

(b) that the cause of death was multiple organ failure secondary to necrotising fasciitis and toxin producing organisms;

(c) that there is no evidence of any precautions which might have avoided the death of the deceased;

(d) that the death of the deceased was not caused by any defect in a system of work;

(e) that the following facts are relevant to the circumstances of death:

(1) The deceased was known to have a drug problem for several years prior to her death.

(2) The deceased attended at the Casualty Department of Stobhill Hospital at 14.35 hours on 29 April 2000. She was complaining of pain in the left buttock radiating down into the leg. She admitted to having injected heroin into the buttock approximately five days previously since when the injection site had become red, hot, swollen and painful. Her pulse rate and temperature were a little raised. She was seen by a member of the medical staff at 17.20 hours. A 10cm by 8 cm area of cellulitis was noted. There was no evidence of deep vein thrombosis. The doctor prescribed antibiotics in the form of fluxloxacillin and penicillin v and the deceased was asked to return in 24 hours.

(3) The deceased duly returned to Stobhill Hospital at 14.00 hours on 30 April. The cellulitis was noted to be much improved and surrounding redness less angry. She complained of persistent pain and was prescribed painkillers and anti-inflamatories. She was told that there ought to be improvement every 24 hours over the next five to seven days failing which she should return.

(4) On 6 May 2000 at 01.00 hours the deceased attended at the Accident and Emergency Department of Victoria Infirmary, the presenting complaint being described as sudden illness. Her temperature was very low and her pulse rapid. She admitted to having "muscle popped" in the right arm and left buttock a week ago. She right arm was swollen from the shoulder to the forearm and there was hard red areas over the left buttock and right flank. Necrotising fasciitis was suspected and she was immediately admitted and referred to surgeons. Her white cell count was recorded at 84.5 which is extremely high. She was given broad spectrum antibiotics intravenously.

(5) Thereafter in theatre fasciotomies were performed on the right upper arm and left buttock. There was significant muscle tension but the muscles appeared otherwise pink and healthy with no sign of pus or necrosis. Specimens were taken for histology and bacteriology and she was transferred to the Intensive Treatment Unit.

(6) Shortly thereafter the deceased showed signs of respiratory distress. This was confirmed by x-ray. Despite efforts to stabilise her condition she died at 02.40 hours on 7 May.

(7) Post-mortem examination revealed effusions in her pleural and pericardic cavities with marked oedema of the lungs all consistent with multiple organ failure. Microscopic examination of subcutaneous tissue and muscle showed areas of haemorrhage and necrosis consistent with necrotising fasciitis/synergistic gangrene. The overall clinical and post-mortem picture was accordingly of death resulting from multiple organ failure caused by a toxin producing organism.

[1] For my comments on the background to the multiplicity of deaths of injecting drug users in Glasgow during the period April to August 2000 reference is made to the General Note appended to the Determination in the case of Andrea McQuilter.

[2] This case provides a good example of the difficulty of detecting necrotising fasciitis. Despite surgical intervention no pus or necrosis was seen in the buttock area although a small area was detected post-mortem. The high white cell count indicates that even with minimal necrosis the deceased was suffering from a massive infection.

[3] The only other matter of significance is the fact that the deceased attended hospital and was treated on 29 April. From the improvement in her condition as a result of the administration of antibiotics it is reasonable to conclude that this treatment was appropriate, and that the subsequent development of fatal infection was not directly linked to her condition on first presentation. From her comment about muscle popping "a week ago", and having regard to the usual period in which clostridum novyi infection become established, it is likely that she injected contaminated heroin after her first attendance at hospital.