Inquiry Determines NHS Staff Could Have Prevented Patient’s Suicide

An investigation has determined that personnel at NHS failed to capitalize on multiple opportunities to avert a woman’s self-inflicted death while she was hospitalized. Dr. Sara MacRae, a former psychiatrist, died by suicide in her room at the Royal Edinburgh psychiatric hospital (REH) in March 2020. During a fatal accident inquiry (FAI), testimony revealed that her son, Christopher MacRae, provided a nurse with “clear evidence” of his mother’s intent to commit suicide merely hours prior to her death. The FAI has now concluded that this nurse did not appropriately respond to this information, and that “serious failings” characterized the treatment and care provided to Dr. MacRae by NHS Lothian. Sheriff Alison Stirling, in her official ruling, stated that NHS Lothian had “failed to appreciate the significance” of certain mistakes and oversights in the matter. NHS Lothian indicated that a review was conducted following the death, resulting in a comprehensive action plan for improvements. Christopher MacRae, aged 30, served as the primary caregiver for his mother, who had experienced mental illnesses for many decades. He commented: “It took so much fighting just to get an inquiry in the first place but I feel like this is only the start in terms of ensuring things change after this.” Warning: This article contains distressing content Dr. MacRae, diagnosed with a schizoaffective disorder, had been admitted to the hospital for a period of six weeks prior to her death. The 55-year-old was directed to attend the REH due to the severe exacerbation of her mental health issues, which had originated in the 1990s. Christopher had previously recounted how his mother displayed evidence of her intention to end her life on the day of her death. He conveyed this information to nurse Rado Rzeznicki, who, according to Christopher, pledged to search his mother’s room; however, the search was not conducted. Sheriff Alison Stirling, in her ruling, stated that Dr. MacRae’s death could realistically have been prevented if her room had been inspected, her son’s warnings had been appropriately documented, and she had received more vigilant observation from staff. Sheriff Stirling identified that the limited accessibility to Dr. MacRae’s medical records, which contained information regarding prior similar suicide attempts, constituted a “defect” within NHS Lothian’s operational systems. Counsel for NHS Lothian proposed during a hearing that the ward experienced “additional pressure” owing to Covid. Nevertheless, Sheriff Stirling asserted that this was “not an excuse,” considering that on 17 March 2020, Covid was not recognized as the transformative event it subsequently became. Sheriff Stirling issued several recommendations for enhancing NHS Lothian’s procedures concerning mental health patients. She further remarked: “Much of this inquiry related to an absence of awareness of protocols and a failure to record information.” “In my opinion there are areas where the heath board has failed to appreciate the significance of the errors and omissions. There are areas where their position was not supported by the evidence of their own chief nurse”. Christopher and his family expressed their approval of Sheriff Stirling’s official finding. In a public statement, they declared: “We hope that broad recognition of these deficiencies and corrective action at the institutional, regional and national level, will begin to bring the management of mental health patients in line with expectations in other areas of healthcare.” Earlier this year, BBC Scotland disclosed that the door in Dr. MacRae’s room had been evaluated as a “high risk” for suicide attempts in the year preceding her death. However, it has still not been substituted, and a £5m initiative aimed at upgrading all single bedroom doors at the REH has not commenced – despite the project being labeled as “urgent” in 2022 – owing to financial constraints. Dr. Tracey Gillies, Medical Director for NHS Lothian, stated: “We once again express our sincere condolences to Christopher and his family.” “Following Dr MacRae’s death, a Serious Adverse Event Review was carried out, led by qualified individuals out with NHS Lothian. The output of this was an extensive improvement action plan, which has been worked through and audited.” “It is important to stress that the doors within the Royal Edinburgh Hospital are compliant and meet the required safety standards.” Should you have been impacted by the themes in this report, assistance and support can be accessed via BBC Action Line. Copyright 2024 BBC. All rights reserved. The BBC bears no responsibility for the material on external websites. Information regarding our policy on external linking is available.