CALLS have been made for a shake-up of Scotland's system of fatal accident inquiries after the formal inquest into the death of a hospital patient took an "unacceptable" six years to complete.

Sheriff Johanna Johnston urged the Crown Office to ensure its procedures were "sufficient to avoid any family having to endure such long delays" as those seen in the case of Ronald McAllister, who died in 2006.

She also raised concerns that lessons regarding training and other procedures had not been learned by NHS Greater Glasgow and Clyde (NHSGGC) after Mr McAllister's death from brain damage and bronchial pneumonia at Stobhill Hospital.

He had been undergoing dialysis treatment for kidney failure following a myeloma.

Sheriff Johnston said: "I consider that there has been an unacceptable delay in bringing the inquiry into the circumstances of the death of Mr McAllister to a conclusion.

"The periods of inactivity by the Crown are likely to have led to further upset and anxiety for the family of Mr McAllister.

"It is fortunate that the difficulties with the alarm system on the dialysis machine were highlighted by the research in 2007 and changes made to practice in dialysis units and that this was independent of any fatal accident inquiry."

Mr McAllister's daughters Andrea Little and Beverley Taylor, who are seeking compensation, said it was extremely worrying that health board staff were still displaying a lack of knowledge in operating dialysis machines.

They added: "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."

Fatal accident inquiries have been a cornerstone of the judicial process since 1895. They are fact-finding exercises carried out in the public interest into some non-suspicious unnatural deaths to uncover any defects in procedure that could be rectified.

Procurator-fiscals investigate about 14,000 sudden deaths each year, with about 50 to 60 fatal accident inquiries in each year.

Mr McAllister, of Carmyle, Glasgow, died from brain damage after a needle became dislodged during treatment, causing him to be deprived of blood and oxygen for a period of time after a cardiac arrest.

Research the following year into the use of venous pressure alarms in detecting whether needles have dislodged took into account Mr McAllister's death and led to a conclusion that they could not be relied upon. This led to a UK-wide change in procedures.

Andrew Henderson, acting for Mr McAllister's daughters, said he had written to a procurator-fiscal in December 2008, calling for an inquiry, but the Crown Office only petitioned the court for one nearly three years later. It blamed the delays to Mr McAllister's case on "staffing issues".

Mr McAllister's daughters added: "Our father's death was avoidable - It is extremely worrying that six years on from our father's death the inquiry still identified failings in the haemo-dialysis training provided by NHSGGC health board and that staff are still displaying a lack of knowledge in operating dialysis machines."

Legal firm Thompsons said Scotland should follow the lead of the English coroner's court system and set up inquests immediately after an unnatural death. It said in 29% of cases where a death occurs at work no inquiry is carried out.

The families of three men who died when the Flying Phantom tugboat capsized in the River Clyde more than five years ago are still waiting for an inquiry.

NHSGGC would not comment as the issue is an ongoing legal matter.

The Crown Office said the establishment of a Scottish Fatalities Investigation Unit, launched in 2011, allows all non-suspicious death investigations to be carried out "thoroughly and expeditiously by dedicated specialists".