DETERMINATION UNDER THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF ANDREW JOHN SORLEY [2012] ScotSC 35 (09 March 2012)

Parties

Procedural Posture

Fatal Accident Inquiry / Determination After Full Inquiry

Legal Issues

1. 1 What were the circumstances of Andrew John Sorley's death in custody?
2. 2 What was the cause of death?
3. 3 Were there reasonable precautions whereby the death might have been avoided?

Ratio Decidendi

Andrew John Sorley died of Streptococcus Pneumonia Meningitis while in custody. The cause of death was established by post mortem. The medical and nursing assessments were generally appropriate, but a reasonable precaution whereby the death might have been avoided was for Nurse Richardson to have conducted a further assessment within two hours of her initial visit, which may have revealed deterioration and prompted earlier medical intervention. There was no defect in the system of working that contributed to the death, and the absence of medical records on transfer was not causative. The inquiry is not to apportion blame but to identify circumstances and possible precautions.

Court Disposition

Formal findings as to time, place, and cause of death. Determination that a reasonable precaution whereby the death might have been avoided was a further assessment by Nurse Richardson within two hours of her initial visit. No finding of systemic defect or other relevant factors causative of death.

Orders

• Determination under s.6(1)(a): Andrew John Sorley died at 10:17 am on 20 June 2008 in the Southern General Hospital, Glasgow, while in lawful custody.
• Determination under s.6(1)(b): Cause of death was Streptococcus Pneumonia Meningitis.