Scottish Sheriff Court Decisions

At various points in the Inquiry, mention was made of a shortage of police officers. For example, both Sergeant Clark and Sergeant Farquharson mentioned this, as did Inspector Merchant, whose evidence was that he had 13 night-shift officers and one from an earlier shift, whereas the full complement was 21, and not 14. This shortage did not have any direct effect on the events with which the Inquiry was concerned. Nevertheless, it is possible that had there been more staff, there might have been a quicker response to the information which had been given about Alison Duguid. It is obviously a matter of public concern if Grampian Police are short of resources. I say no more on this point, except to draw attention to the fact that this matter is also mentioned in the Chief Constable's most recent Annual Report, published only a short while ago.

At the time of McCulloch's telephone call (around 7pm on 15^th March), Devon Lloyd Harvey was with Thomas Pirie. They were in a blue Mercedes motor vehicle and they drove to the Poundstretcher Store in Great Northern Road, Aberdeen, after which they were detained along with Steven McCulloch, suspected of offences under the Misuse of Drugs Act. All three were taken to Bucksburn Police Office. In the course of that journey, which is a relatively short one, neither Devon Lloyd Harvey nor Steven McCulloch made any mention of Alison Duguid. Upon their arrival at Bucksburn, each detainee was searched put in a cell for the purposes of a strip search.

While Devon Lloyd Harvey was being strip-searched, he was asking when he would be released. PC Gary Hunter (9 years' service), who was the reporting officer, told him that he and the others would be searched and thereafter their vehicle would be searched. Devon Lloyd Harvey was also told that it was for the Custody Sergeant to make a decision regarding his release.

The search of Devon Lloyd Harvey began at 8.04pm (Crown Production No. 7). During that Devon Lloyd Harvey told PC Hunter that he was on his way to collect insulin for "a lassie." PC Hunter asked if the person was insulin- dependent, but Devon Lloyd Harvey said that he did not know. Equally, he did not know whether the injection was a "supper injection" i.e. one taken at the same time as the last meal of the day. At that point, Devon Lloyd Harvey was calm and composed and was not showing any concern. In particular, he was not giving the impression that there was any urgency about the insulin. Furthermore, Devon Lloyd Harvey seemed to be satisfied about the information which he had been given regarding his release. PC Hunter formed the view that, in common with many people in custody, Devon Lloyd Harvey was possibly looking for an excuse to get out of the police station more quickly. Having searched Devon Lloyd Harvey, PC Hunter searched Steven McCulloch who made no mention of Alison Duguid.

Following upon the searches of Devon Lloyd Harvey, Steven McCulloch and Thomas Pirie, their vehicle was searched and because drugs were found in that vehicle, both Harvey and McCulloch were detained and they were to be interviewed later.

Sergeant Clark has 16 years' police service having become a sergeant in April 2001. On 15^th March 2002, she was on the nightshift 10 pm until 6am at the Tillydrone Police Office. While there should have been 22 officers on duty, there were 13 and she, and custody sergeant at Bucksburn.

Her role was supervisory. She would speak to the outgoing shift to find out if anything was to impact on her shift. They too would pass on information about any incidents of note to her. She had been told that the previous shift had been busy and that there were three people in custody. There had been 18 Grade 1 calls. She was intending to catch up on her paperwork before going on leave and she was instructed by Inspector Merchant to concentrate on that paperwork. That said, she checked on the incidents on the computer and was listening to radio transmissions and in particular to incidents to which the Control Room were sending out officers. She noted that PCs Hunter and Moreland had had a car in the afternoon and still had it after 10pm and so at 1.00am, following upon her conversation with Sergeant Farquharson at 0.55am, (Crown Production No. 31) she went to Mastrick to hand over the car and took a custody to Bucksburn where she remained, because of a shortage of staff. She did not pick up on any particular urgency in relation to Sergeant Farquharson's phone call, but she did take it as a request for a car to go to Fountain Grange as soon as possible. While she was willing to go to 15 Fountain Grange herself, she described it as "a right druggy flat" and accordingly was reluctant to go on her own. She was advised by Sergeant Farquharson of another incident in Byron Square where a person on a bicycle was threatening an old man. Sergeant Farquharson told her that he was going to get Bravo 3/1 to attend, but that everyone else was tied up and he asked Sergeant Clark if there was any possibility of getting a car to go. She advised him that Bravo 6/1 were sitting outside Bucksburn at that time and that she would take a car over to them. She checked the STORM incident at about 2.00am. Throughout her involvement, no sense of real urgency was communicated to her. If it had been, she would not have missed it. When the alarm call came in about premises in Dyce, Sergeant Clark sent Bravo 1/1 there first as that type of call takes priority, and Dyce was also closer. Sergeant Clerk was unable to say whether her actions would have been different if she had known that Alison Duguid was ill and needed insulin badly, as much would depend on the circumstances. If she had known of that, she would have told her officers.

At 1.58am, PC Morag Menzies, the Assistant Controller in the Control Room to whom Sergeant Farquharson had transferred the STORM incident regarding Alison Duguid, contacted PC Kane who was on duty with PC Skivington. She asked them to go to 15 Fountain Grange. She told them that the information that she had got had come in approximately 2 hours previously, viz:- that people who were in custody at Bucksburn had been en route "To get insulin for an Alison Duguid at 15 Fountain Grange". Bravo 3/1 were asked to go round there and see if she was "okay". (Crown Production No. 32) PC Kane asked where the insulin was and was told that the people in custody had not actually got it. PC Kane asked, "So it's just to make sure she's okay and sort out what the problem is". Answer, "It's just to make sure she's okay". Shortly thereafter, PCs Kane and Skivington attended at 15 Fountain Grange and at 2.10am they got back to PC Menzies and asked her to confirm that the address was 15 Fountain Grange. When she confirmed that they said "Well in that case we're not getting any reply at the intercom, do you have any further instructions regarding this". (Crown Production No. 33)

Thereafter, at 2.12am PC Menzies contacted Sergeant Clark to ask where Gary Hunter was. PC Menzies explained that finally after 2 hours they had managed to get a unit round and she said, "There's no answer" and asked Sergeant Clark if she wanted anything further done. Sergeant Clark said the police should find out "If she was definitely there". Sergeant Clark said that she would try to track down PC Hunter to see if any of the people in custody had keys to the flat. After that PC Menzies contacted Bravo 3/1 and asked them to stand down "meantime". (Crown Production No. 34)

At 2.21am, Sergeant Clark spoke to Inspector Milne in the Control Room and advised him that persons in custody in Bucksburn had been on their way to see Alison Duguid "because she needed an insulin shot or something". Sergeant Clark told him that PC Kane was unable to "get a response," but Sergeant Clark also advised Inspector Milne that one of the custodies had had keys for 15 Fountain Grange which Sergeant Clark now had. She said that she would go herself, but that she would prefer not to. Inspector Milne asked whether it was an address check to which Sergeant Clark responded by saying that it was to make sure that Alison Duguid was not in the flat "unwell". Inspector Milne then said that he was looking to see who was clear. Sergeant Clark advised that Bravo 7/1 had got custodies at Bucksburn, Bravo 6/1 were at one time at Hillhead but she did not know whether they were still there. Bravo 6/1 subsequently advised that they had finished with the incident at Hillhead Halls, but needed to refuel. Eventually, Sergeant Clark asked Bravo 1/1 to attend first of all to an alarm call at Dyce and then go over to 15 Fountain Grange.

PC Debbie Burnett now has 2 years' service. At the time of Alison Duguid's death, she was on probation. PC Michael Rennie has 15 years' service and at that time, he was working with PC Burnett as her supervising officer.

On Friday, 15^th March 2002, they came on duty at 10.00pm, their call sign being Bravo 1/1. Each recalled the night as being a busy one. They received their request from the Control Room at 0.16am to attend at 15 Fountain Grange to see if they could trace Alison Duguid whom they were told was a diabetic and that people in custody were about to get some insulin for her. They were instructed to attend at the address to trace the female and see if she was "okay." (Crown Production No. 27). However, at 0.17am, there was a conversation between Bravo 1/1 and Bravo 2/1 in respect of an incident at Summerhill, which Bravo 1/1 attended in their car. A front door had been smashed and Bravo 1/1 were on the lookout for a male whose description they gave to Bravo 2/1 who were assisting in this search. A male was subsequently arrested at 0.23am and taken to Bucksburn Police Station. (Crown Production No. 29). There is no doubt that Bravo 1/1 received the call regarding Alison Duguid at 0.16am, but neither PC Burnett nor PC Rennie could remember that. At 0.34am, PC Burnett contacted the Control Room to ask the Control Room to note that Bravo 1/1 were still attending at Bucksburn with the male arrested for the breach of the peace. (Production No. 30). During that conversation, the Control Room asked if this was in any way related to Fountain Grange. PC Burnett said that it was a separate matter and she said that she would contact the Control Room when they could get back to Fountain Grange.

At 1.15am, Bravo 1/1 were in Lee Crescent North, Bridge of Don searching for a drunk driver about whom they had been given some information. At 1.25am, there was a Grade 1 call which required them to attend at the Granite Ten Pin Bowling Club in Don Street, Aberdeen, where there was a disturbance. That resulted in persons being taken to Bucksburn. A number of things occupied Bravo 1/1 after they had taken the male to Bucksburn (Crown Production No. 30). While they were at Bucksburn, an alarm call was received in respect of industrial premises at Dyce. The alarm had been activated. That was at 2.15am. As instructed by Sergeant Clark, they went out to their car, but someone knocked on the window indicating that Sergeant Clark wished a word about something. PC Burnett went into speak to Sergeant Clark and she was told that the people in custody from the previous day had been on their way to get insulin and Bravo 1/1 were asked to go to the address and check that Alison Duguid was "okay." PC Burnett remembered that the call was an address check, but she was not told that Alison Duguid was a diabetic nor was there any information about her being ill. She said that Sergeant Clark told her that a unit had gone to the address, but could not get in. By this time, Sergeant Clark had the keys of the flat. PC Burnett discussed the alarm call with Sergeant Clark and Bravo 1/1 was directed to attend to the alarm call first because it was closer. PC Burnett then returned to the car and updated PC Rennie about what she had been told by Sergeant Clark. In her evidence, PC Burnett said that she thought that she would have told him that they had another job to go to, discussed the nature of that call, but also told him about the address check in relation of 15 Fountain Grange. PC Burnett's understanding of an address check was that someone might be missing or that police should ascertain whether someone lived there or pass on a message to someone who did live there.

When they attended at Dyce, they spoke to the keyholder who had arrived and the premises seemed to be intact. That probably took about 15 minutes and then they went to 15 Fountain Grange.

15 Fountain Grange is a block of flats in the Tillydrone area of Aberdeen, a general view of which can be seen in Crown Production No. 1, Photograph 38. Photograph 29 shows the picture of the front door of the block which PCs Burnett and Rennie were able to enter using the key. Photograph 30 shows the entrance way and Flat 15 on the bottom floor which is reached by going downstairs. PC Rennie's recollection was that the officers who had visited had not been able to get into the flat and that was what he recalled being told by PC Burnett.

On entering the building, they went downstairs, but when they knocked on the door, the door itself opened. They could not see why that was because the door appeared to be completely shut as they approached it. PC Burnett entered the flat first. The hall was in darkness and she shouted that they were the police. She switched on the hall light and went into the living room, where the television was on, but she could not remember whether the lights were. PC Rennie's recollection was that the lights were on. Photograph 8 is a photograph of the living room which shows a sofa on the right hand side of the coffee table. Alison Duguid was lying on the sofa under a duvet. PC. Burnett, who had met Alison Duguid before, recognised her.

At that point, PC Burnett was at the side of the sofa, bending down. She asked Alison Duguid her name and why she was at that flat which was not her usual address, but, in evidence, she could not remember getting any response. Shortly thereafter, she spoke to her again and asked if she was "okay." The reply was that someone was away to get insulin. Her speech was a bit slurred and she appeared to both PCs to have just woken up out of a sleep. Both PCs looked round the flat, but there was no other person in the flat: they were also looking for medication. PC Rennie looked in the kitchen cupboards and in the fridge which contained only one microwave meal, but no insulin. There were various drug-related items around the flat as can be seen in Crown Production No. 1, Photographs 16 and 17.

Various Photographs in the book, e.g. Nos. 11, 12, 13, 14 and 15 show the coffee table in the living room. In Photograph 15, there is a close-up of a purple case which Doctor Grieve, one of the medical witnesses, identified as being an insulin kit. Both PCs were clear in their recollection that that was not at the flat when they attended. While they did not know what an insulin kit looked like, they did say that this purple case was distinctive and they would have remembered it had it been there.

PC Burnett was unable to say why they were looking for medication as she was of the opinion that they would not have been able to do anything had they found it. PC Rennie's position was that had they found medication they would have attempted to ascertain whether Alison Duguid was able to administer this herself. Both PCs were attempting to check the information which had come from Devon Lloyd Harvey.

After the search of the flat, the PCs returned to the living room and PC Rennie asked Alison Duguid when she had had her insulin last and her response was "three days". At that point, she was lying on the sofa; now and then she would turn round to see whether the PCs were still there and would open her eyes, but she did not get up. The PCs spoke to her from time to time, but were not constantly engaging her in conversation and neither of them could recall precisely what form the conversation took.

At 3.16am, there was a three-way conversation involving Bravo 3/1, namely PCs Kane and Skivington, the Control Room and PCs Burnett and Rennie (Bravo 1/1). PCs Rennie and Burnett indicated that they were at 15 Fountain Grange with the female, but they wanted to know from Bravo 3/1 whether those in custody had said precisely where the insulin was which they said that they were going to collect. Bravo 3/1's response was, "All we knew was it was an address in Marischal Street down near the Castlegate. They didn't know the address so really she's on her own. I don't know if she can try and get it from somewhere else". Bravo 1/1's response was, "She's not making much sense. Thanks anyway". Bravo 3/1 then asked, "Is she safe and well?" Bravo 1/1 replied, "Difficult to say meantime. She's sort of in and out of sleep". Bravo 3/1 said, "I'll go back and speak to them [the custodies] and see what I can get and I'll get back to you". At 3.22am, Bravo 3/1 contacted PC Menzies at the Control Room, having spoken to the custodies and said that the insulin "would be with the occupiers of 39 Peacock Court in the Castlegate. That's where she left her insulin earlier on". That information was subsequently given to Bravo 1/1 who then asked for a Voters' Roll check and a telephone number if there was one for that address. PC Menzies advised that there was no name listed for 39 Peacock Court and no previous calls.

Bravo 1/1 then asked if it was possible for someone from Queen Street to attend at the address and Bravo 1/1 confirmed to PC Menzies that the requirement was to "attend at locus and pick up the insulin". PC Menzies then asked PC Richard Taylor at Fonthill to go to 39 Peacock Court. Sometime thereafter, PC Taylor advised the Control Room that he had been unable to get in to 39 Peacock Court and that he was standing down. This information was then passed on to Bravo 1/1 at 3.52am. At 4.03am, PC Burnett contacted the Control Room and spoke to Inspector Milne and said, "Regarding that call at Fountain Grange the female, she doesn't seem to be in any form of distress, she's sleeping". Inspector Milne asked, "She's sleeping!" and the response was "Yes like a baby". (Crown Production No. 39)

The two PCs were at 15 Fountain Grange for approximately 50 minutes, during which time Alison Duguid remained on the sofa occasionally opening her eyes and turning round to see whether they were still there. When she was spoken to she responded, but she did not become fully roused as a result of this conversation. They got the impression that their presence was not entirely welcome. She was not, however, showing any signs of distress, and was not indicating that she was thirsty, or in need of any medication.

Both PCs formed the view that Alison Duguid had not been at 15 Fountain Grange for very long, firstly, because they were under the impression that the previous unit had not got a response from the flat but secondly because Alison Duguid's clothes were on the coffee table. There was no sign of any keys. They thought that she had been out for the night and had just returned. The two PCs thought from the circumstances and also from her demeanour that she had been out drinking. Her demeanour did not change throughout the time that they were there. The two PCs tried to smell her breath, but she turned away and PC Burnett said that she did not get close enough in order to smell her breath.

There was a mobile telephone in the living room which PC Rennie picked up. The telephone was on and he searched through the numbers there, looking for those which might be friends or relatives, but the only names that he could find were nicknames or other names which did not give him any assistance. There were no names which appeared to be those of relatives. The two PCs did discuss the possibility of calling an ambulance, but they were of the opinion that she did not require an ambulance at that time.

Despite the fact that no one could get into Peacock Court, neither PC thought it necessary to make any further enquiries at that time. In the first of the two phone calls from the flat, it was said that she was not making much sense. Both accepted in retrospect that they had probably not sought enough information because they did not have very much knowledge about diabetes, but both thought that they had made sufficient enquiries at the time given the information and knowledge which they had. PC Rennie thought that Alison Duguid was controlling her insulin by her diet. Both PCs also accepted that if the call had been marked as a concern call they might have acted differently, but they were unable to say precisely what different course or courses of action they would have adopted. They certainly accepted that if they had been told that Alison Duguid was ill they would have acted differently.

PC Burnett had seen Alison Duguid on an earlier occasion when she formed the opinion that Alison Duguid was under the influence of either drugs or alcohol. The police had attended premises where she was between 4am and 5am in response to a call about a male who alleged that he had been assaulted. The male went into the bedroom and tried to waken Alison Duguid but could not do so. He tried again but failed. PC Burnett accepted that what she had seen on that occasion influenced her thinking in the early morning of Saturday 16 March. The PCs later telephoned in to say that Alison Duguid was sleeping and did not seem to be in any distress. (Crown Production No. 39)

Thomas Pirie and Devon Lloyd Harvey were released from Bucksburn Police Station between 7 and 8am on Saturday 16 March. There were picked up by Robert Foreman. There is no evidence which suggests that Harvey inquired of the police at Bucksburn about Alison Duguid's condition, nor that he went to the flat at 15 Fountain Grange, or attempted to ascertain how she was. In the evening, at approximately 5pm, a neighbour in the block of flats at Fountain Grange heard the sound of deep groaning coming from No. 15. He looked through the letterbox and saw Alison Duguid lying with her head in the hall and her body in the living room. He repeatedly called "Hello," but there was no response and she continued to groan. He sought assistance from another neighbour, who stood outside No 15 while the first neighbour looked through the window. At the point, the first neighbour was of the opinion that Alison Duguid was under the influence of either drink or drugs. At approximately 7pm, the first neighbour could still hear groaning, but at 10pm, he could not hear any further groaning. On both occasions, he chose to take no further action.

At 9.30am, on Sunday 17 March, PCs McConnach and Logie attended at 15 Fountain Grange. They were looking for someone in connection with an alleged robbery. They gained entry to the block of flats. When they knocked the door of No. 15, they got no response and so they looked through the letterbox. They saw Alison Duguid lying on her back in the living room with her head in the hallway. They contacted the Control Room to send an ambulance. PC McConnach forced entry to the flat, but Alison Duguid appeared to be dead. The ambulance arrived at 9.40am, and the ambulance officers confirmed that she was dead, and at 10.05am, life was pronounced extinct by Dr. Linda McKay, a GP.

This came from Doctor Ann Gold, a consultant in diabetes and general medicine at Aberdeen Royal Infirmary and Doctor James Grieve, the forensic pathologist.

Doctor Gold had seen Alison Duguid when she was admitted to hospital with an infection, but had not seen her at the diabetic clinic. Doctor Gold's evidence was that there are two types of diabetes; type 1 which tends to affect younger people, usually children, and type 2 which is usually diagnosed later in life. Type 2 is more common and can be controlled by diet whereas type 1 makes that person insulin-dependent. She estimated that between 10,000 and 13,000 people in Grampian are diabetics and of these 2,500 would be type 1 diabetics.

The body of a type 1 diabetic cannot use glucose properly and without insulin the blood/glucose level can decline resulting in a hypoglycaemia. If the blood/ glucose level is raised, the result is hyperglycaemia. The insulin required by a diabetic is usually inserted by the person using an insulin pen which may be done between 2 and 5 times per day. Such a person's blood level needs to be constantly monitored also. Accordingly, he or she requires to adhere to a diet and be tested regularly.

A person with poorer control of their insulin requirements may suffer from eye problems (retinopathy) and kidney problems amongst other things. In a severe case, the sugar will escape through the kidneys and eventually the person becomes semi-comatose and may more easily slip into keto-acidosis which can be fatal. Persons who have had diabetes for a long time have a better understanding of their condition and should therefore be more knowledgeable about what to do in relation to their insulin requirements, diet and blood testing.

Doctor Gold's evidence was that Alison Duguid was not a good attender at the diabetic clinic. The clinic has a practice of writing to a patient's G.P. should that person fail to attend on three occasions. When asked about Alison Duguid's drug use, she knew little about this, but her evidence was that a person who has been taking drugs might be less attentive to their insulin needs.

Her position was that a person who had been without insulin for three days would probably be in and out of sleep and unable to talk and these symptoms are indicative of a lack of insulin. She was not in any doubt that had Alison Duguid been admitted at the time she was last seen alive, she would have survived, an opinion shared by Dr. Grieve. What causes death is the blood becoming acidic which forces the heart into cardiac arrest. There may also be a smell of acetone on the breath, but sometimes the smell may not be there, and some people cannot detect the smell even if it is there.

She said that any severe illness can give rise to slurring of the speech and that an untrained person would not necessarily know that the slurred speech was the result of diabetes. She said that the fact that the neither the hospital nor the clinic had seen Alison Duguid suggested that she was managing with her insulin. On the assumption that Alison Duguid had missed one injection of insulin of a two-insulin doze per day regime, Doctor Gold's position was that by the end of that day, and certainly by the next day, the diabetic would know that something was wrong, possibly because of an unusual thirst. She was asked what conclusion a lay person might draw from someone with slurred speech, who was turning round and away again, and who appeared to be in and out of sleep. Her response was that that was consistent not only with a lack of insulin, but also a person being under the influence of drink.

Doctor Grieve, the forensic pathologist, had been called to 15 Fountain Grange on 17^th March 2002 and he described the position that Alison Duguid was in on his arrival. With reference to Crown Production No. 1, Photograph 15, which shows the holder for the insulin, his position was that there was no insulin in the vials. The post mortem examination, (Crown Production No. 14) which had been carried, out by Drs. Grieve and Roberts revealed an extremely high glucose level--52.5%. That is indicative of uncontrolled diabetes with no insulin. The Toxicology Report (Crown Production No. 15) disclosed a relatively-recent exposure to cocaine and that there was both cocaine and morphine in the urine. When asked about slurred speech and someone who seemed to be in and out of sleep, and turning round now and then, Dr Grieve's evidence was that that was indicative of deprivation of insulin, but these symptoms were not "insulin-deprivation" specific, and were equally compatible with someone who was under the influence or drink or drugs. He also said that he had failed regularly to pick up any smell from the breath of persons whom he was later told were diabetics.

All parties were agreed that my determination under s.6(1)(a) of the 1976 Act should be that Alison Aikman Duguid died between 7pm on 16^th March and 9.30am on 17^th March 2002 and that for the purposes of s. 6(1)(b), the cause of death should be as certified by Doctor Grieve, viz:- diabetic keto-acidosis. There were however different submissions about (i) any reasonable precautions which might have prevented the death (s.6(1)(c)); (ii) any defects in any system of working which may have prevented the death; (s.6(1)(d)); and any other relevant factors. (s. 6(1)(e))

Had Alison Duguid taken her insulin as she had been instructed, her death would not have resulted. It was clear from the evidence that PCs Burnett and Rennie had a doubt about Alison Duguid's condition and accordingly they should have sought medical assistance.

The STORM system worked and while the system of grading calls could be more sophisticated, lack of sophistication did not contribute in any way to Alison Duguid's death.

All of the relevant information was available to PC Hunter and that should have been made available to all the others who were involved. PC Hunter himself omitted to tell Sergeant Farquharson that Alison Duguid needed her insulin "badly". There was a need to classify calls correctly. This call was classified as an "address check," whereas the majority of police witnesses thought it should have been classified as a concern call. Had the call been marked as a concern call in the first place, that would have automatically been supervised, whereas an address check would not. The information on the STORM incident omitted the fact that Alison Duguid was said to be "ill" and needing her insulin "badly." The receivers of information should check all salient features with those giving the information. Those on the beat were not familiar with the way in which calls were prioritised by the Control Room. The alarm call should not have been given more priority than the call to 15 Fountain Grange.

It was reasonable for them to get medical assistance. When they got to the flat, they knew from the persons in custody that someone was going to get insulin for Alison Duguid and that was confirmed by her. At that point, therefore, the statement made by the custodies had been corroborated and there was no need for the officers to investigate the story any further. It was obvious from the telephone call made at 3.16am that Alison Duguid was not safe and well and that is what PCs Rennie and Burnett had been asked to ascertain. They could have and should have made further enquiries of her about her condition. They should have called an ambulance because even if they had found her insulin either in the flat at 15 Fountain Grange or at 39 Peacock Court, they could not have administered it and so medical assistance would have been required. They knew that she required insulin and there was no improvement in her condition in the 50 minutes in which they were in the flat. They did not make a proper assessment of her condition. They thought that she was drunk and there was little or no evidence to support that. They also thought that she had just come back from a night out and yet there were no keys for the flat. They also assumed that Alison Duguid was controlling her problems by her diet, but there was no evidence of that.

The grading and the classification of calls left a great deal to be desired. Furthermore, there was no requirement on those in the Control Room to check that jobs had been dealt with. That was a matter which was left to the officers themselves to advise the Control Room. Furthermore, officers did not have proper training in relation to diabetes.

When officers are advised of the need for medication, they should get it. The system of classification of calls should be more sophisticated and there should be a more sophisticated grading system. Grampian Police themselves are contemplating having five gradings rather than four and that would result from a splitting of Grade 2. The calls in the higher grading in Grade 2 should be attended to within 3 minutes.

While mention was made of resources, the lack of resources did not have any direct affect on the outcome.

PC Hunter did all that could be expected of him in that he sought advice on what do about the information which he had received from Harvey, the custody and he acted immediately on that advice and contacted the Control Room.

PCs Burnett and Rennie gave evidence that Alison Duguid's speech was slurred and that she was in and out of sleep, but they did not notice any smell from her breath.

Her condition at 3am when PCs Burnett and Rennie first arrived might have been consistent with Alison Duguid being was under the influence of drink which would accord with the evidence given by Doctor Grieve. She could also have been under the influence of drugs which also came from the evidence of Doctor Grieve and the toxicology report and the existence of drug paraphernalia around the flat. The third possibility was that she was suffering from hyperglycaemia, but the evidence of Doctor Grieve and Doctor Gold was that the symptoms which she exhibited were not specific to diabetes.

Had Alison Duguid taken her insulin and been administering it properly, she would not have died. She would not have died if she had not failed to make the doctor's appointments.

So far as PCs Burnett and Rennie were concerned, they may, with hindsight, have acted differently, but every situation is different and a lot depends on the information which comes from other officers. Their assessment of the situation was made without having certain vital pieces of information. Firstly, they were not given any sense of urgency; secondly, they were not told that Alison Duguid was ill and thirdly, they were not told about the need for insulin. In these circumstances, it was not unreasonable for them to conclude that she was either drunk or under the influence of drugs and that to some extent may have been influenced by PC Burnett's previous dealings with Alison Duguid. Accordingly, their assessment could not be regarded as an unreasonable one. There was no doubt that they could have made further checks, but Alison Duguid herself had made no request for help and no request for insulin. It was clear that they had considered calling an ambulance, but the police also have to consider the priorities of the ambulance drivers.

Staffing levels which were poor had to be addressed. There was no specific recommendation in relation to training in First Aid.

Sergeant Farquharson acted in accordance with recognised procedures and there was no doubt that Grade 2 was the appropriate method of classifying that particular call. No criticism could be made of him for classifying it as an address check because what he did immediately was to transfer the call and he expected it to be dealt with immediately. He became aware only an hour later that those instructed had not been able to attend. Sergeant Clark became involved at that stage to ensure that the incident was followed up and that a car was sent as quickly as possible and she acted on that following upon her discussion with Sergeant Farquharson. No criticism could be levelled at Sergeant Clark by becoming involved in other incidents. It was clear that she contemplated going herself but because of the reputation of the flat, she decided not to attend. As a sergeant, she was entitled to rely on the officers attending to make a proper assessment.

It was Alison Duguid's responsibility to take proper care of herself and manage her insulin problem properly. Her neglect was reckless. Devon Lloyd Harvey and Steven McCulloch appeared to have shown absolutely no concern for Alison Duguid following upon their release, and the neighbours who looked through the letter box could have chosen to assist.

So far as Alison Duguid was concerned, she had a poor history of diabetic control and a question which remains unanswered is why she was without insulin for three days. It has to be asked why she cancelled the various doctor's appointments. Furthermore, she could have got help herself earlier and one has to ask why she took both cocaine and heroin during her stay at 15 Fountain Grange. It may be that her judgement was impaired as a result of these drugs. There was a mobile telephone in the flat at 15 Fountain Grange which she could have used. The actions of Sergeants Clark and Farquharson did not therefore contribute in any way to Alison Duguid's death.

Ms Nunn's submission was that no one person had fully appreciated the significance of Alison Duguid's condition in that PC Hunter learned something from the custodies and from then on varying degrees of information were passed on to other officers. The responses of the officers had to be seen against the background of 292 incidents including 40 created between midnight and 4am amongst which were 16 Grade 1 calls. There were therefore a number of serious ongoing incidents. Her submission was that Sergeant Farquharson's actions would have been the same even if the call had been described in some other way, but she accepted that to describe a call as a "concern call" meant supervision by the Control Room and ultimately by the Inspector there. However, there was insufficient evidence to say that this would have made a difference to the outcome. In her submission, the call was properly classified as a Grade 2 call, and that being so, the issue which arose was that of time scale. Bravo 1/1 had become involved in other incidents and while it would have been ideal to advise the Control Room of that, the circumstances may have prevented that being done. When ultimately Bravo 1/1 did call, they had no information about Alison Duguid being ill, nor about her needing her insulin badly.

Five of these were listed, the overriding one being that Alison Duguid herself ought to have taken greater care for her welfare. Secondly, had PCs Rennie and Burnett sought medical assistance that might have avoided Alison Duguid's death. Her death might equally have been avoided if her friends had checked on her or if the neighbours had phoned for medical assistance. Her death might also have been avoided had the fact that Alison Duguid was ill been placed on the STORM system.

She submitted that I should not make any finding under this heading unless I was satisfied that there was a causal connection between the defects and the ultimate death and in her submission, there was no such causal connection. She advised that the call-handling methods are constantly under the scrutiny of the police and that a new system for dealing with calls by a new centre and indeed a more sophisticated grading system was currently being put in place.

In this connection, Ms Nunn concurred with the submission of the Procurator-fiscal Depute which was that so far as First Aid training is concerned, that is a matter best determined by the Association of Chief Police Officers in consultation with appropriate medical advisers. She advised that Grampian Police are currently exploring the possibility of further training in judgement and decision-making and to that end they had instructed Doctor John Maule of The Centre of Decision Making at the University of Leeds.

She submitted that resources were clearly a relevant factor because seven units had to deal with 100 calls each. Finally, her position was that Grampian Police deeply regretted not getting the desired result namely, the survival of Alison Duguid.

The purpose of a Fatal Accident Inquiry is not to identify criminal activities, nor matters which may give rise to civil proceedings. In terms of the 1976 Act, the sheriff is required to determine the following:-

It is inevitable that a Fatal Accident Inquiry will be a very unpleasant experience for the relatives and friends of the person who died. Such Inquiries take place some time after the death and may result in distress to those who have been trying to adjust to the loss of a loved one. It is often not possible for such Inquiries to be conducted earlier, because the Crown has to carry out its own investigations, before deciding whether or not to conduct a Fatal Accident Inquiry. It is sometimes the case that the relatives and friends learn certain things at a Fatal Accident Inquiry of which they were previously unaware, and that too is distressing. It may also be distressing for those who participate as representatives at such an Inquiry. However, such Inquiries can serve a very useful function in that the whole circumstances of the death are subjected to careful scrutiny, and if lessons have to be learnt as a result, the sheriff, who is independent of those represented at the Inquiry, can make whatever observations and recommendations he or she regards as appropriate.

Grampian Police offered their condolences to the family at the conclusion of the Inquiry and it is proper that I should add mine also.

Alison Duguid had been without insulin for three days. It may be that the circumstances in which she moved from 39 Peacock Court around midnight on Tuesday 12th March 2002, were upsetting, or that she had to move in a hurry and hence she forgot to take her insulin with her. However, at the Inquiry, nothing was said, or produced, which would explain why she had not taken her insulin prior to her move. Likewise no explanation was given for her failing to seek help the following day, i.e. the Wednesday. According to Dr Gold's evidence, Alison Duguid would have been aware possibly at the end of the first day on which she had not taken insulin, and certainly by the end of the second, i.e. the Thursday, that she needed insulin. Again, no reason was given for her failure to attend the doctor's appointments on Wednesday 13^th and Thursday 14 March. Had she done any of these things, her death would not have occurred. When the police arrived at 15 Fountain Grange in the early hours of the Saturday morning, they saw on the coffee table beside the sofa a mobile telephone which was switched on, and had she used it, she could have summoned help, perhaps from family members or the ambulance service. She had used a telephone to contact Devon Lloyd Harvey at 4pm on Friday 15 March to say that she was sick. If she realised that he was not coming with the insulin, she could have used the telephone to get help. Her recent exposure to cocaine would not have assisted her concentration on her health.

It is a matter of admission that Devon Lloyd Harvey and Thomas Pirie were released from custody at Bucksburn Police Station between 7 and 8am on Saturday 16 March 2002. They were picked up by Robert Foreman. There was nothing to suggest that Harvey asked the Police about Alison Duguid's condition, nor that there was anything which prevented him from visiting the flat. Whether he did so is not known, but it is clear that he did nothing about Alison Duguid and seems simply to have abandoned her.

One neighbour at Fountain Grange erroneously thought that the deep groans which were coming from Alison Duguid within the No. 15 at approximately 5pm on Saturday 16 March were coming from someone who was under the influence of drink or drugs and took no further action. He could still hear the groans at approximately 7pm, but heard nothing at 10pm. He took no further action at that time either. Given his conclusion, which was not an unreasonable one, it is not surprising that he took not further action.

It would be easy to say that PC Hunter ought to have telephoned for ambulance or sought medical advice when he was told about Alison Duguid's condition by Devon Lloyd Harvey. It would be easy to blame PC Hunter for not passing on to Sergeant Farquharson all of the information which he received from Harvey. It would be easy to blame Sergeant Farquharson for failing to pick up on some of the information which PC Hunter did pass on. It would be easy to blame Sergeant Clark for nor sending a car to 15 Fountain Grange earlier. Likewise, it would be easy to blame PCs Burnett and Rennie for failing to call for an ambulance when they attended at the flat. However, things always seem clearer with the benefit of hindsight, and apparently-easy solutions have to looked at carefully.

It would not have been appropriate for PC Hunter to summon an ambulance as soon as he was given the information about Alison Duguid by Devon Lloyd Harvey. It was not only appropriate, but sensible, for PC Hunter to check that the information was accurate, but also to find out whether Alison Duguid was at, or still at, the flat at 15 Fountain Grange. Had PC Hunter immediately asked for an ambulance to go there, and the information had turned out not to be true, or that Alison Duguid was no longer at the flat, he could have been criticised for diverting an ambulance and possibly depriving some needy person of its services.

So far as the dilution of information which was a feature of this Inquiry, one has to accept that when human beings communicate orally, and even in writing, there can be misunderstandings. None of us can honestly say that we have never failed to pick up on something essential or important, even although we would have tried our best not to do so. That being so, while it is unfortunate that these things do happen, and particularly unfortunate when there are sad consequences, it is not possible to make any practicable recommendation which would eliminate, or even reduce the possibility of these things happening. It is easy to say that vital information ought to be repeated, but in many instances, such information will be passed to or by the police in circumstances which demand a speedy response, and the recipient of vital information in such a case will be concentrating not only on the information, but considering also the appropriate response. It is also possible to judge things with the benefit of hindsight, but that is also dangerous. It is particularly dangerous to do that in relation to Sergeant Clark's decision to send a car to the alarm call in Dyce first. That could have been a serious matter; it turned out not to be, but at the time, how could she know? It would also be inappropriate to lose sight of how Sergeant Farquharson reacted, which was to instruct someone to go as soon as possible to the flat. Those so instructed were sent out to deal with other things, such as a drunk driver, and two disturbances. These too were high-priority matters over which Sergeant Farquharson had little control. He might have classified the call in a different way, but it is impossible to say that that of itself would have resulted in a different and less tragic outcome.

It was inevitable and appropriate that the actions of PCs Burnett and Rennie were examined in great detail. They were the last officers of Grampian Police to see Alison Duguid alive. They accepted that, with the benefit of hindsight, they should have acted differently. What they did, however, was to act on the information which they had at the time, which was not complete. It was suggested that they came to an inappropriate conclusion when they assumed that Alison Duguid was under the influence of drink, and that she had recently returned home. The real issue, in my opinion, is whether they could be criticised in any way for coming to the conclusion that she was not unwell, and hence not in need of any medical assistance. There was evidence around which would have entitled them to assume that she had just returned home. They understood that another unit had failed to get into the flat only a short time previously. She had partially undressed, but had not put her clothes away. The fact that no keys were seen is consistent both with a recent return as it is with Alison Duguid's having been in the flat most or all of the evening. The conditions in the flat may also have pointed to something other than a need for insulin. For example, there were drug paraphernalia in the flat which was an address well known to the police and associated by them with illegal drug use. While there is no suggestion that Alison Duguid was a drug addict, there were traces in her urine of a recent intake of cocaine and morphine. In my opinion, the conclusion reached by PCs Burnett and Rennie that Alison Duguid was not unwell was not an unreasonable one. At no time, during their time in the flat did Alison Duguid tell the PCs that she needed insulin, far less that she needed it badly. Devon Lloyd Harvey may have said that, but it is somewhat surprising that Alison Duguid did not say that herself. (That, in itself, would have made PC Rennie's assumption that she was controlling her diabetes by her diet, a not unreasonable one.) She did say that someone was on their way to get insulin, but that did not, in itself, indicate urgency, and the urgency was not something of which PCs Burnett and Rennie were aware. There was nothing in what Alison Duguid did or said that would have made that clear. She did not say that she was thirsty, but even if she had that might not have meant very much to someone unfamiliar with a need for insulin. Her condition, which admittedly did not improve while they were there, was not apparently getting worse either. A different decision could have been taken when they were advised that there no one could get a response from 39 Peacock Court, but, once again, they had to consider the whole circumstances, against the background information of which they were aware, and while their conclusion was, with the benefit of hindsight, incorrect, it was not in my opinion an unreasonable one to make in the situation with which they were faced.

The PCs were looking for medication, and their decision might have been different had it been found, because, it may be that Alison Duguid would not have been able to inject it, but we have no means of knowing how she would have reacted had insulin been found. It was suggested that when Alison Duguid mentioned that she had last had insulin three days before, that corroborated the information given by Devon Lloyd Harvey. That may be so, but these PCs did not have all of that information, and crucially, Alison Duguid did not actually request any insulin. It was also suggested that even if the insulin had been found, Alison Duguid would not have been in a fit state to self-administer, and so they should have sought medical attention. However, they would have sought medical attention had she indicated that she wanted to have the insulin, but was unable to do what was required herself. They could not have administered it to her.

It was submitted that if police officers are in doubt about a person's medical condition, they should summon medical assistance immediately, and in particular, PCs Burnett and Rennie ought to have done that. In my opinion, to recommend that officers who are in such doubt, should always summon medical help is putting an inappropriate constraint on the exercise of their functions. Every situation is different, and properly-trained officers must be left to exercise judgment. For example, someone might be in urgent need of medical attention, but something even more urgent might also arise and it is inevitable that the more urgent matter be given priority, and in such a case, the best that the police might be able to do would be to ask a civilian to contact the emergency services for the person in need of medical attention. No one who is unfamiliar with the day-to-day work of police officers should make any recommendations about how they should carry out their tasks unless there is something glaringly obvious that ought to be done, or not done. If something comes into that category, it is likely that senior officers will already have addressed it.

PCs Burnett and Rennie honestly admitted to having a doubt. However their conclusion was not, as I have said inappropriate, as there was nothing about Alison Duguid's behaviour and the whole circumstances which pointed unambiguously to the conclusion that the PCs were faced with someone who was seriously ill and needed medical attention as soon as possible.

There was also a submission that the First Aid knowledge of the officers was inadequate. At the training course for police officers, which deals among other things with First Aid, there was some mention of diabetes. However, the Association of Chief Police Officers has decided, acting upon advice from the relevant medical college, that the instruction in First Aid for officers should be restricted to the "ABC," i.e. airways, breathing and circulation. It would not be appropriate for me to make any suggestion which conflicts with that advice.

Comments were made about how calls were dealt with and, in particular, about the Grade 2 category. Grampian Police themselves accept that the four grading categories for calls are not as sophisticated as they might be and they intend to have five categories instead. That said, there will always be doubt about the category into which some calls ought to be put. Grampian Police also intend to have a new system for dealing with all calls. That said, the absence of these things did not, in my opinion, contribute to the death. What matters was the response. Sergeant Farquharson responded immediately and to suggest that the call should have been described in another way is to lose sight of that fact. There was no dispute about the classification of the call as a Grade 2. The fact that those instructed to attend by Sergeant Farquharson were not able to do so, because they were needed to attend to other matters, is not something for which anyone can be or should be criticised. Even if the call had been described differently, e.g. as a concern call, that would not necessarily have resulted in a speedier response given the other demands on police resources on the evening and morning in question.

I was advised that a new call centre is being set up to deal with all calls and that that will improve maters, because there will be a better system for analysing calls and prioritising them. I was also told that the existing Grade 2 category will be split and so Grade 2 calls in the new system will have more priority than those in the new Grade 3. The current expectation is that calls in the Grade 2 category will be answered within 2 hours and it was suggested that I might recommend a period within which calls in the new Grade 2 category should be answered. I have no doubt that Grampian Police will address this matter and it is one which I believe is best left to them.

Against that background, my determination is as stated above.

I should say that throughout the Inquiry, I was impressed by those who gave evidence. They gave it honestly, which is, of course, what is expected. However, some of those who did give evidence were relatively-inexperienced police officers and some must have known that their actions were going to be the subject of careful and searching analysis, and could not be certain about the outcome. It is commendable that, despite that, they gave their evidence candidly. It is important for all to appreciate that police officers have a difficult and, at times, an unpleasant job to do, often with less than a full complement of staff. The fact that they carry out their tasks with the dedication which was obvious to me at the Inquiry is a tribute to them and those who train and supervise them.