The death of a paedophile rapist prisoner in hospital in Stirlingshire could have been avoided, a sheriff has ruled.
After a fatal accident inquiry, the sheriff stated Peter Carter’s discharge from Forth Valley Hospital in June 2019, where he had arrived from Glenochil Prison, may have contributed to his death.
Sheriff Neil Bowie also said blood tests taken the day before he passed should have been passed to clinicians more quickly.
He said the system of reporting blood tests, while changing, remains defective.
The sheriff made four recommendations for Forth Valley Health Board in relation to his findings after the inquiry at Alloa Sheriff Court.
Carter, 53, was jailed in 2015 for nine years for attacking children in Argyll.
After some seven months of abdominal pain, he was taken to Forth Valley Royal Hospital on May 23 2019 and treated for suspected cholecystitis – a suspected inflamed gall bladder – and discharged on June 4.
Still ill, blood tests were taken in Glenochil on June 10 and he was returned to hospital the next day.
Under the knife on June 11, he was found to have a perforated gangrenous ischaemic small bowel, gangrenous gallbladder and gangrenous colon and he died later that day.
In a determination released this week, Sheriff Collins wrote: “The system in place at Forth Valley Royal Hospital laboratory relating to the clinical oversight / review of patient blood tests by clinical scientists between 23 May 2019 and 11 June 2019 was defective.
“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.
“Had there been an adequate system of clinical review, it is reasonable to suggest that
the blood test results of 4 June and 10 June 2019 would have been reported
to the relevant clinician.
“As such this defect contributed to the death of Mr Carter.”
The sheriff noted Forth Valley Health Board’s assertion “that since Mr Carter’s death there have been concentrated efforts to make the process for discharge to prison from hospital safer.”
However, he said: “They recognised that greater efforts required to be made to increase staff awareness of that process.
“It was clear in evidence… that while the changes instigated were introduced almost 2 years ago, it was not being applied consistently.”
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 Health Board 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.”
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