A gardener has died after he was speared in the groin by a bamboo cane while working at a historic estate, a sheriff has ruled.Norman MacKenzie, 68, fell onto the bamboo while he was cutting topiary hedges at Darnaway Castle on the Moray Estate in Elgin, Scotland.The father of two slipped while coming down a step ladder and was cut by a bamboo cane used for plants in a flowerbed.He initially declined treatment but sought medical advice after noticing swelling in his genitals.He was rushed to hospital in Elgin before being transferred to Aberdeen Royal Infirmary in September 2024.Mr MacKenzie, who had worked for Moray Estates for 40 years, was initially stable and receiving treatment, but his condition deteriorated.While awaiting surgery on his wounds, he developed blood poisoning and necrotising fasciitis, a severe bacterial condition. Medical staff desperately tried to save him, but he died on September 21, four days after his accident. Norman MacKenzie, 68, slipped and fell onto a bamboo cane from his ladder while cutting a topiary hedge. The cane stabbed him in the groin and he died of a severe infection four days later Mr McKenzie had worked at the Moray Estate in Elgin for 40 years. They have since removed all bamboo from their sunken gardens and flower bedsThe sheriff noted that the target time for him to undergo surgery was not met and put it down as a system failure. A fatal accident inquiry at Elgin Sheriff Court heard he suffered 'a blunt, penetrating and dirty injury' and could reasonably have been prescribed antibiotics under Grampian Health Board protocols.Sheriff David B Harvie found the use of a henchman platform ladder may have avoided the accident and said Mr MacKenzie should not have been cutting hedges at height due to existing medical conditions.However, he made no recommendations after hearing Moray Estates and Grampian Health Board had reviewed and updated protocols in the wake of the accident.A written judgement said: 'Since Mr MacKenzie's death, Moray Estates Development Limited has reviewed and formalised its supervision and reporting structure, making it clear that the individual now employed in Mr MacKenzie's role is under the Estate Forestry Department.'Moray Estates Development Limited has recognised that the experience and/or seniority of workers is not a substitute for structured oversight.'Moray Estates Development Limited has removed all canes from the sunken gardens and flower beds.'He added: 'Following evidence heard during the first day of the Inquiry, Grampian Health Board recognised that the way in which discussions at its Morbidity and Mortality meetings were recorded was not adequate and has since adopted the Royal College of Surgeons recommended system.'The absence of an adequate record had an impact on the extent of further evidence required at the Inquiry to establish the circumstances of Mr MacKenzie's death.'The target time for surgery was not met due to competing emergencies. There was no evidence at the inquiry that the delay caused or contributed to Mr MacKenzie's death.'However, following evidence led on the second day of the Inquiry, the Board has further amended its approach to record keeping at Morbidity and Mortality meetings to ensure that a surgical target time not being met would now be recorded as a system failure.'The sheriff offered his condolences to Mr MacKenzie's family and friends.Andrew Howard, managing director of Moray Estates, said: 'Norman was a key member of our team for 40 years and a highly respected colleague.'We were all devastated at his untimely death and still miss him. Our thoughts remain with his family, who continue to mourn his loss.'Since the accident, we have reviewed and formalised our supervision and reporting structure and reinforced to all staff members that all accidents or near misses must be reported so they can be fully investigated.'The Sheriff has taken that into account and has concluded that no recommendations are required.'NHS Grampian's chief officer for acute services Geraldine Fraser said: 'We extend our sincere condolences to Mr MacKenzie's family.'We acknowledge the outcome of this inquiry, noting the findings reflect that clinical decisions were reasonable, based on the information available at the time'We have since made system and process improvements for how we record meetings and review surgical target times.'