DETERMINATION IN TERMS OF THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF JOHN JOHNSTON [2011] ScotSC 200 (22 December 2011)

DETERMINATION IN TERMS OF THE FATAL ACCIDENTS AND SUDDEN DEATHS INQUIRY (SCOTLAND) ACT 1976 INTO THE DEATH OF JOHN JOHNSTON [2011] ScotSC 200 (22 December 2011)

The primary cause of death was sepsis, most probably caused by infection of the TPN line, which itself was necessitated by complications from a misplaced PEG tube—a known but rare complication. There was no evidence of reasonable precautions or defects in systems that could have avoided the death, nor any other relevant circumstances. The medical care provided was appropriate given the circumstances and co-morbidities.

Citation
[2011] ScotSC 200
Parties
Deceased: John Johnston; Procurator Fiscal Depute (crown): Ms N Henderson; Family Representative: Mr Clark; NHS Fife Representative: Ms Lake
Jurisdiction
Scotland
Judgment Date
22 December 2011
Procedural Posture
Fatal Accident Inquiry / Determination
Outcome
Death due to sepsis, infection of a Total Parenteral Nutrition (TPN) line, and complications of PEG insertion; no reasonable precautions or system defects identified; no other relevant circumstances.
Legal Topics
Medical Negligence, Hospital Procedure, Causation, Complications of Medical Procedures, Death Certification
Medical Law Coroners and Fatal Accident Inquiries Medical Negligence Hospital Procedure Causation Complications of Medical Procedures Death Certification

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Parties

John Johnston

Deceased

Ms N Henderson

Procurator Fiscal Depute (crown)

Mr Clark

Family Representative

Ms Lake

NHS Fife Representative

Procedural Posture

Fatal Accident Inquiry / Determination

Legal Issues

  1. 1 What was the cause of John Johnston's death?
  2. 2 Were there reasonable precautions whereby the death might have been avoided?
  3. 3 Were there defects in any system of work which contributed to the death?

Ratio Decidendi

The primary cause of death was sepsis, most probably caused by infection of the TPN line, which itself was necessitated by complications from a misplaced PEG tube—a known but rare complication. There was no evidence of reasonable precautions or defects in systems that could have avoided the death, nor any other relevant circumstances. The medical care provided was appropriate given the circumstances and co-morbidities.

Court Disposition

Death due to sepsis, infection of a Total Parenteral Nutrition (TPN) line, and complications of PEG insertion; no reasonable precautions or system defects identified; no other relevant circumstances.