Six years on from Greater Glasgow Health Board hospital death, evidence highlights staff operating dialysis equipment still display worrying lack of knowledge.
The Crown Office has been urged to improve practices around fatal accident inquiries to ensure families are not forced to endure unacceptable waits to determine the circumstances of accidental deaths of loved ones.
The call for improvements was made by Sheriff Johanna Johnson, QC in her determination into the death of Ronald McAllister, who died in 2006 after undergoing dialysis treatment for renal failure following myeloma at Glasgow Royal Infirmary. Mr McAllister’s daughters have waited more than six years for the FAI into their father’s death to be heard.
Ronald McAllister died aged 63 on 13th October 2006 after a needle dislodged during dialysis resulting in hypoxic brain damage as a result of being deprived of blood and oxygen for a period of time following a cardiac arrest.
Mr McAllister was due to have routine dialysis on 10th October at Glasgow Royal Infirmary. However, due to chest pains as the result of a recent accident it was decided he should receive the dialysis in a bed rather than a chair to allow him to also receive pain relief at the same time. He was admitted as an in patient and administered with morphine before his dialysis started.
45 minutes into the treatment an alarm sounded alerting hospital staff to a problem. Mr McAllister was found to be unconscious and lying in a pool of blood as a result of the venous needle dislodging. He was resuscitated and taken to the intensive care unit at Glasgow’s Stobhill Hospital but had suffered extensive neurological damage from which he failed to recover. Mr McAllister later died on 13th October 2006.
The fatal accident inquiry has concluded that while dislodgment of needles is rare the risk cannot be wholly eliminated. However, the inquiry has identified steps which could have been taken to minimise the risks. The FAI also highlighted an unacceptable delay in bringing the inquiry to a conclusion as well as well as concerns over training and procedures at Greater Glasgow Health Board. In giving evidence Lead Nurse Isobel Brown was unable to direct the inquiry to any documents in use by GGHB to record the regular checks of dialysis patients or the settings of guards on dialysis machines.
In a joint statement issued by Ronald McAllister’s daughters Andrea Little and Beverley Taylor, they said:
“While we are pleased that the circumstances surrounding our father’s death have finally been fully investigated we are saddened and disappointed it has taken such a long time to reach this point.
“It has taken over six years since our father died for us to have these answers and in our opinion the stress and the toll that has taken on our everyday lives and our families is totally unacceptable. No family should be made to suffer in this way for such a sustained period of time and we truly hope the Crown Office will take heed of this determination and seek to improve the way they operate when dealing with fatal accident inquiries.
“Our father’s death was avoidable and while needle dislodgement is not common Sheriff Johnson found that better systems could have been in place to monitor our father more closely on the night in question. It is extremely worrying that six years on from our father’s death the inquiry still identified failings in the haemodialysis training provided by Greater Glasgow Health Board and that staff are still displaying a lack of knowledge in operating dialysis machines. This is despite GGHB conducting an internal review and supposedly implementing changes to protocol to address these issues.
“We sincerely hope lessons will be learned from the circumstances surrounding our father’s death which will go some way towards preventing another family losing a loved one like this.”
Thompsons Partner Andrew Henderson, acting for Ronald McAllister’s family added:
“This has been a long and arduous process and simply highlights the poor system we have in place in this country to deal with fatal accident inquiries. This family have suffered the immense loss of their father and while trying to come to terms with this have had to fight for six years for answers which should have been available to them far sooner.
“The inquiry has highlighted failings on the part of Greater Glasgow Health Board which could have contributed to the death of Ronald McAllister and while it is recognised the health board has taken steps, independently from the inquiry, to improve practices around dialysis and needle dislodgement it is evident that there is certainly room for improvement. It is crucial that the recommendations from this inquiry are followed up to reduce the risk of a similar tragedy.”
The fatal accident inquiry system in Scotland has been subject to criticism in the past leading to Labour MSP Patricia Ferguson announcing her intention to lodge a members’ Bill to radically overhaul the entire FAI system.
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