Prisoner died after being discharged from hospital too soon, inquiry finds

A health board has been ordered to review its process for discharging prisoners back into custody after a man died after being returned too soon.

Peter Carter died on June 11, 2019, at Forth Valley Royal Hospital after being transferred from HMP Glenochil and undergoing surgery. 

The 53-year-old was jailed for nine years in 2015 after being found guilty of raping two girls at a farmhouse in Argyll.

He sentence was extended for three years in 2015 at the High Court of Justiciary.

Carter was admitted to Forth Valley Royal Hospital with suspected cholecystitis on May 23, 2019.

He was treated and discharged from hospital on June 4, 2019.

On June 11, 2019, Carter attended the emergency department at Forth Valley Royal Hospital with abdominal pain.

The report said his symptoms had deteriorated over the previous three days and following an examination it was thought that Carter was in septic shock.

Carter was reviewed by the surgical team at FVRH, and he was scheduled to undergo a CT scan as well as have a catheter inserted.

The CT scan showed an ischaemic small bowel with occlusion of the superior mesenteric artery and coeliac trunk.

An emergency laparotomy was performed which showed a perforated gangrenous ischaemic small bowel, gangrenous gallbladder and gangrenous right colon to transverse colon.

He condition was deemed non-survivable and he was moved to the ICU to remain on a ventilator until his family arrived.

His treatment was later withdrawn and he was pronounced dead.

Following a fatal accident inquiry, Sheriff Neil Bowie found that had “reasonable precautions” been taken, Carter’s death could have been avoided.

The sheriff made four recommendations for Forth Valley Health Board in regards to clinical oversight of laboratory test results and the discharge process of patients to a prison setting.

Sheriff Bowie said Carter should not have been discharged on June 4, adding that his death may have been avoided if he had remained in the hospital.

He also identified defective systems within the hospital’s labs between May 23 and June 11, 2019, which contributed to the death of Carter.

“There was then and now no system that provided for adequate levels of clinical oversight/review of blood test results that are outwith normal parameters,” the report said.

“Had there been an adequate system of clinical review, it is reasonable to suggest that the blood test results of June 10 and June 4 would have been reported to the relevant clinician.”

Sheriff Bowie ordered the NHS Forth Valley Health Board to conduct a review of the clinical oversight
of test results within its laboratories and to establish a system of parameters increasing clinical oversight of blood test results.

He added that the health board should “urgently increase” awareness of the set criteria applied to reporting abnormal blood test results to all clinicians.

NHS Forth Valley Health Board was also told to review its discharge process for patients to a prison setting, increasing awareness of the checklist created by Dr Sayers.

Sheriff Bowie told the health board to increase its awareness of medication available in a prison setting and consider making it a requirement to review outstanding test results prior to discharge.

NHS Forth Valley accepted the recommendation and said they are working to ensure they are all met.

The procurator fiscal, who acts in the public interest, led evidence on the facts and circumstances of Carter’s death at the inquiry in which other interested parties were represented.  

Following the publication of the determination, procurator fiscal Andy Shanks, who leads on fatalities investigations for COPFS said:   “The sheriff’s determination, which makes recommendations in relation to reviews of clinical oversight and discharge process, is extensive and detailed. 

“The FAI followed a thorough and comprehensive investigation by the Procurator Fiscal who ensured that the full facts and circumstances of Mr Carter’s death were presented in evidence. ”  

A spokesperson for NHS Forth Valley said: “We fully accept the report recommendations and have already made a number of changes to our laboratory and discharge arrangements to address the issues highlighted.

“Further work is also underway to ensure that all of the recommendations are met within the required timescales.”