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FAI into the Death of William Charters Brown, Greenock Sheriff Court, 7th May 2010


In terms of s.6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that William Charters Brown died at The Coronary Care Unit of Inverclyde Royal Hospital, Greenock on 23rd November 2007 at 7.00am. In terms of s.6(1)(b), the cause of death was pulmonary thrombo-embolism, due to deep venous thrombosis of the right calf. No other formal determinations were made.

Mr Brown had undergone a heart transplant fourteen years prior to his death. He also suffered from arthritis and had previously been treated for a brain abscess and was prescribed numerous medications including steroids. Immediately prior to his death he was incarcerated in HMP Gateside Prison in Greenock, having been charged with homicide, during which incident he had also received a number of injuries including a stab wound to his right hip.

On 6 November 2007, whilst in the prison, he complained of chest pain radiating through to his back following which he was transferred to Inverclyde Royal Hospital. Over the next few days his condition appeared to stabilise and he was discharged back to prison on 14 November 2007. On 19 November he once again complained of shortness of breath and chest pain, and was transferred back to Inverclyde Royal Hospital. On the morning of 23 November he developed sudden onset severe chest pain before collapsing. Cardiopulmonary resuscitation was attempted but this was unsuccessful, and he was formally declared dead at 0700 hours. Mr. Borwn's fatal pulmonary embolism was diagnosed post mortem.
The sheriff found that there were no reasonable precautions which could have been taken to avoid the death. The pulmonary embolism could only have been discovered by an MRI scan; however, this would not necessarily have shown that there was a thrombosis that would cause death. The diagnosis made was acute coronary syndrome and not pulmonary embolism. This diagnosis was appropriate given the deceased's symptoms.