INQUIRY UNDER THE FATAL ACCIDENTS AND INQUIRIES (SCOTLAND) ACT 1976 INTO THE SUDDEN DEATH OF JOHN WILLOCK [2013] ScotSC 79 (08 October 2013)

Parties

Procedural Posture

Fatal Accident Inquiry / Determination

Legal Issues

1. 1 Whether reasonable precautions could have prevented the death of John Willock
2. 2 Whether defects in the NHS 24 and Out of Hours Service systems contributed to the death
3. 3 Whether the actions of individual healthcare professionals met the required standard of care

Ratio Decidendi

The court found that there were failures by NHS 24 call handlers and nurse advisors to follow established protocols for return callers, to accurately record and communicate relevant clinical information, and to arrange for a face-to-face medical assessment when indicated by the patient's deteriorating condition. These failures constituted defects in the system of work and missed reasonable precautions that might have avoided the death. However, the court could not determine on the balance of probabilities that earlier intervention would have definitively prevented Mr Willock's death, given the uncertainty of the underlying medical cause and the rapid progression of his illness.

Court Disposition

Death due to septicaemia, source uncertain; defects in NHS 24 and Out of Hours Service systems contributed to missed opportunities for intervention; recommendations for improved protocols and training.

Orders

• Determination issued under s.6 of the 1976 Act setting out circumstances of death, cause, and defects in system.
• Recommendations for NHS 24 and Out of Hours Service to review and improve protocols for return callers, handover procedures, and clinical triage.