Prisoner who died in hospital 'incorrectly triaged', inquiry finds

An inquiry into the death of a prisoner in Edinburgh found he should’ve been correctly triaged in hospital.

Keith Munro, also known as Keith Martin or Keith Jordan, died on November 15, 2022, at the Marie Curie Hospital.

The 57-year-old was in legal custody and in the care of the state at the time of his death.

Sheriff Adrian Fraser found that one reasonable precaution would have been to “correctly triage Mr Munro’s referral on March 11, 2021 and place him on the urgent suspicion of cancer pathway.”

The findings said: “Lothian Health Board correctly accept that there was an error in the triaging of Mr Munro’s referral.

“Having regard to the information contained in the referral form, Mr Munro should have been identified as a patient suited to the ‘urgent suspicion of cancer’ pathway and ought to have been triaged accordingly.

“This appears to have arisen due to human error.”

The cause of Mr Munro’s death was found to be complications of metastatic oesophageal cancer.

Sheriff Fraser made no recommendations.

The purpose of a Fatal Accident Inquiry (FAI) includes determining the cause of death; the circumstances in which the deaths occurred, and to establish what, if any, reasonable precautions could have been taken, and could be implemented in the future, to minimise the risk of future deaths in similar circumstances. 

Unlike criminal proceedings, FAIs are inquisitorial in nature and are used to establish facts rather than to apportion blame. 

Following the publication of the determination, Andy Shanks of the Crown Office and Procurator Fiscal Service, Scotland’s death investigation authority, said: 

“We note the Sheriff’s determination.

“The Procurator Fiscal ensured that the full facts and circumstances of Mr Munro’s death were presented in evidence at the mandatory Fatal Accident Inquiry.”

NHS Lothian has been approached for comment.