NHS Ayrshire and Arran fined over patient death

Nicola Black died at Crosshouse Hospital in Kilmarnock on 31 August 2010

A health board has been fined £50,000 after a vulnerable patient took her own life at a hospital in Kilmarnock.

NHS Ayrshire and Arran admitted health and safety breaches over the death of 33-year-old Nicola Black at Crosshouse Hospital on 31 August 2010.

Kilmarnock Sheriff Court heard she was put in a room where previously identified risk had not been addressed.

Sheriff Brian Murphy said Ms Black's death was "entirely avoidable", adding: "I regard these failures as serious."

The court heard that Ms Black, who had a history of mental health problems, was airlifted from the Isle of Arran after an earlier attempt to take her life.

After recovering in a high dependency ward, she was transferred to the hospital's psychiatric ward but was noted only as being at risk of absconding, not taking her life.

She later found unconscious by a healthcare assistant, having hanged herself, and could not be revived.

'Systematic failure'

Sheriff Murphy extended his sympathy to Ms Black's parents in court, telling them that despite the passage of four years it could not have been easy to hear how their daughter's death was avoidable.

He described the "systemic failure" that reached up into management.

Outside court, Ms Black's parents Ian and Janette, formerly of Eaglesham, Renfrewshire, but now of Kent, paid tribute to their daughter, a qualified Steiner schools teacher who taught yoga to children, worked in the US and was "creative and full of energy".

Ms Black's father, Ian, 65, former human resources director at Glasgow University, said: "As the hearing found, there was inadequate communication. Procedures were in place but not followed through.

"Nobody seemed to communicate to the healthcare assistants and I think there should have been closer observation from qualified staff."

Ms Black's mother, Janette, 68, a retired social services team leader with East Renfrewshire Council, said: "No amount of fine will bring our daughter back but the important thing is for lessons to be learned, and I'm not entirely confident that will happen.

"The risks were self-evident. If you helicopter a patient from Arran unconscious, having taken a massive overdose, to me and to the man in the street, that shouts 'risk.'"

A spokeswoman for NHS Ayrshire and Arran passed condolences to the family and said: "We regret the failures of services and systems that led to the sad death of Nicola.

"We take seriously any failures in care and have made numerous changes to our processes.

"We have undertaken a significant training programme with our staff since this incident - a point noted by the sheriff in his judgement today."