NHS staff could have stopped suicide - inquiry

Christopher with mum Sara at his graduation ceremony from St Andrews University

NHS staff missed a number of chances to prevent a woman taking her own life in hospital, an inquiry has ruled.

Former psychiatrist Dr Sara MacRae killed herself in her room at the Royal Edinburgh psychiatric hospital (REH) in March 2020.

A fatal accident inquiry (FAI) had heard how her son Christopher MacRae gave a nurse "clear evidence" that his mum was planning her suicide just hours before she died.

The FAI has now ruled this nurse failed to properly act on this and there were "serious failings" in the treatment and care of Dr MacRae by NHS Lothian.

In her determination, Sheriff Alison Stirling said NHS Lothian had "failed to appreciate the significance" of some of the errors and omissions in the case.

NHS Lothian said a review was carried out after the death which led to an extensive improvement action plan.

Christopher MacRae, 30, was the main carer for his mum, who suffered from mental illnesses for decades.

He said: "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."

Christopher says Mellon Udrigle beach in Wester Ross was very close to his mother's heart, and her ashes were scattered there by the family

Warning: This article contains distressing content

Dr MacRae, who had a schizoaffective disorder, had been in hospital for six weeks before she died.

The 55-year-old was ordered to attend the REH because her mental health problems, which stretched back to the 1990s, had become so acute.

Christopher previously told how his mother had shown him evidence that she intended to kill herself on the day she died.

He took this to nurse Rado Rzeznicki, who Christopher said promised to search her room but the search was not carried out.

In her determination, Sheriff Alison Stirling said Dr MacRae's death might realistically have been avoided if her room had been searched, her son's warnings had been properly recorded and she had been more closely observed by staff.

Sheriff Stirling said a lack of easy access to Dr MacRae's medical records, which had details of previous similar attempts to take her own life, was a "defect" in the NHS Lothian's systems.

NHS Lothian's lawyer suggested during a hearing that there was "additional pressure" on the ward due to Covid.

However according to Sheriff Stirling, this was "not an excuse" given that on 17 March 2020, Covid was not known to be the life-changing event it became.

Sheriff Stirling made a number of recommendations on improvements to NHS Lothian's processes for mental health patients.

She added: "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 was the main carer for his mum

Christopher and the family welcomed Sheriff Stirling's determination.

In a statement, they said: "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 revealed the door in Dr MacRae's room had been assessed as a "high risk" for suicide attempts the year before she took her own life.

But it has still not been replaced and a £5m programme to upgrade all the REH's single bedroom doors has not yet started - despite the work being described as "urgent" in 2022 - due to funding pressures.

Dr Tracey Gillies, Medical Director, NHS Lothian said: "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."

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