INQUIRY UNDER THE FATAL ACCIDENTS (SCOTLAND) ACT 1976 INTO THE SUDDEN DEATH OF RONALD WILLIAM MCALLISTER [2013] ScotSC 22 (28 March 2013)

INQUIRY UNDER THE FATAL ACCIDENTS (SCOTLAND) ACT 1976 INTO THE SUDDEN DEATH OF RONALD WILLIAM MCALLISTER [2013] ScotSC 22 (28 March 2013)

The death of Ronald William McAllister was caused by blood loss from the dislodgement of a dialysis cannula during haemodialysis, compounded by insufficient monitoring and suboptimal alarm settings on the dialysis machine. Reasonable precautions, including a second check of needle security, optimal alarm settings, and more frequent monitoring, could have reduced the risk. Staff training and documentation procedures were found to be inadequate at the time.

Citation
[2013] ScotSC 22
Parties
Deceased: Ronald William McAllister; Procurator Fiscal Depute (public Interest): Mr Graham; Representative for the Daughters of the Deceased: Mr Henderson; Representative for Greater Glasgow Health Board: Mr Stewart
Jurisdiction
Scotland
Judgment Date
28 March 2013
Procedural Posture
Fatal Accident Inquiry / Determination After Evidentiary Hearing
Outcome
Findings and recommendations issued; no civil or criminal liability determined.
Legal Topics
Medical Negligence, Hospital Procedures, Haemodialysis Safety, Training of Medical Staff, Medical Device Alarms, Patient Monitoring, Delay in Legal Proceedings
Medical Law Health and Safety Law Coroners and Fatal Accident Inquiries Medical Negligence Hospital Procedures Haemodialysis Safety Training of Medical Staff Medical Device Alarms +2 more

Case Brief

Summary, issues, holding and outcome

More case intelligence is available

Unlock the full research layer for this judgment.

Full judgment text Downloadable case file Legal principles 2 Authorities cited 1 Party arguments 2 Amounts and remedies 3
Sign in to unlock

Parties

Ronald William McAllister

Deceased

Mr Graham

Procurator Fiscal Depute (public Interest)

Mr Henderson

Representative for the Daughters of the Deceased

Mr Stewart

Representative for Greater Glasgow Health Board

Procedural Posture

Fatal Accident Inquiry / Determination After Evidentiary Hearing

Legal Issues

  1. 1 What were the circumstances and causes of the death of Ronald William McAllister?
  2. 2 What reasonable precautions could have prevented the death?
  3. 3 Were there any defects in the system of working which contributed to the death?

Ratio Decidendi

The death of Ronald William McAllister was caused by blood loss from the dislodgement of a dialysis cannula during haemodialysis, compounded by insufficient monitoring and suboptimal alarm settings on the dialysis machine. Reasonable precautions, including a second check of needle security, optimal alarm settings, and more frequent monitoring, could have reduced the risk. Staff training and documentation procedures were found to be inadequate at the time.

Court Disposition

Findings and recommendations issued; no civil or criminal liability determined.

Orders

  • Greater Glasgow Health Board to review staff training in haemodialysis delivery.
  • GGHB to review procedures for documenting and recording patient checks during haemodialysis.