Norma Haq

(4) In terms of Section 6(1)(e) of the said Act the death ought to have been reported to the procurator fiscal in terms of the literature "Death and the Procurator Fiscal"; said literature ought to be sent by the Scottish Executive to managers of private hospitals in addition to NHS hospitals; management in NHS and private hospitals should ensure that all doctors treating patients are aware of the terms of "Death and the Procurator Fiscal"; in any event Mr Hansell should have known such a report was required from his own NHS consultant practice; it would have been appropriate to report to the Scottish Audit of Surgical Mortality (SASM), and effort should be made to encourage the participation of surgeons in private practice in SASM, a voluntary scheme; there should be a system of review of cases in a private hospital such as Ross Hall Hospital where a patient's stay in hospital is longer than expected following an elective procedure; there should be participation in managed clinical networks in specialist areas by consultant surgeons in a private hospital such as Ross Hall Hospital; there should be guidelines for surgeons operating in a private hospital such as Ross Hall, regarding discussion of patients or transfer of patients to specialist care centres where an instrumental perforation of the upper gastro intestinal tract has occurred; that the Department of Health considers issuing guidance to surgeons relating to instrumental perforation of the upper gastro intestinal tract in respect of transfer to specialist care centres.