Fraser John O'Donnell

It is for those reasons that any comments I have made in connection with matters of connectivity, communication and accountability are in the form of observations which I hope those charged with the management of the services will look at in light of the circumstances of Fraser’s death.

For the avoidance of doubt the terms of the protocol, should be revisited to eliminate any ambiguity. Connectivity and communication Victoria Infirmary The strength of the protocol of a department is only as sound as those who operate them. There would have been a better chance of their not being a verbal handover, if both the Scottish Ambulance Service and the Victoria Infirmary accident and emergency management had agreed upon identical protocols reinforced by regular training of both services about them requiring there to be a physical handover in all attempt suicide cases. Dr. Gordon spoke of there being regular management meetings to tighten up procedures. That would appear to be inadequate, if workers operating the system do something different in practice. On the evidence, the ambulance personnel did what they were allowed to do, where the hospital personnel did not. Accountability Once again in this case, the person who made the decision to place Fraser in the general waiting area is not identified, did not give evidence, and therefore gave no account for his or her decision. Dr. Gordon said that he felt personally that he had let Fraser down. He told the inquiry that steps have been taken, but that what happened could happen again. That is not very reassuring. I accept that there is an interaction between the Scottish Ambulance Service and the Victoria Infirmary in the handover of patients and that therefore there has to be a negotiation and agreement as to how to proceed. I accept too that being an emergency service there can be occasions where all presenting may have life threatening conditions. I accept, too, that the physical treatment of Fraser was unlikely to be in that category. That does not prevent the Victoria Infirmary accident and emergency department from taking steps where possible to look at the matter again. I do consider that if, as the inquiry was told, placing an attempt suicide in the general waiting area is very rare occurrence, then it may not be seen as being unduly burdensome for the protocol to be amended to require a staff member taking the decision to place an attempt suicide patient in the general waiting area to require that person to sign the PDF to that effect, although no one suggested that in evidence.