NHS staff missed a number of chances to prevent a Scots mum taking her own life, 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) has heard how her son Christopher MacRae handed nurse Rado Rzeznicki “clear evidence” that his mother planned to take her own life just hours before she passed away.
Rzeznicki promised he would search her room, however the search was not carried out and Dr MacRae was later found dead. The FAI ruled the nurse failed to act properly on the warning 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 negligence in the case. NHS Lothian has confirmed a review was carried out after the death which led to an extensive improvement action plan.
Christopher, 30, was his mum’s main carer, she had been diagnosed with schizoaffective disorder and had been in hospital for six weeks before her death.
Speaking previously, he said: “She reached a point where she felt she could no longer fight, she told me she was considering taking her own life. For 26 years she always said: ‘Don’t worry I’ll be here tomorrow, I’ll just get through the night’.
“This was the first time she had said no, I can’t promise I’ll see you tomorrow – and that was the hardest thing I’ve ever heard.”
In her determination, Sheriff Stirling stated that Dr MacRae’s death might 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 added that a lack of easy access to Dr MacRae’s medical records was a “defect” in the NHS Lothian’s systems.
The health board’s lawyer suggested during a hearing that there was “additional pressure” on the ward due to the Covid-19 pandemic. 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”.
In a statement, Dr MacRae’s family welcomed the determination today.
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.”
Following the publication of the determination, Procurator Fiscal Andy Shanks, who leads on fatalities investigations for Crown Office and Procurator Fiscal Service, said: “We note the Sheriff’s determination and the recommendations made. This was an incident that the Lord Advocate considered the circumstances made a compelling case for a discretionary Fatal Accident Inquiry.
“The Procurator Fiscal ensured that the full facts and circumstances of Dr Macrae’s death were led in evidence. My thoughts remain with the MacRae family at this difficult time.”
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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