Son gives hospital ‘clear evidence’ mother planned suicide

The son of a woman who took her own life in hospital says he gave nurses “clear evidence” that his mother planned to take her own life just hours before she died.

Christopher MacRae confiscates the evidence, hands it to the nurse and asks them to search his mother’s bedroom for more potential danger.

But the search was not carried out and former psychiatrist Dr Sara MacRae committed suicide in her room at the Royal Edinburgh mental hospital (REH) in March 2020.

NHS Lothian has apologized to the MacRae family and improved its processes for identifying patient risks since Dr MacRae’s death.

Warning: This article contains disturbing content

The door to Dr MacRae’s room had been assessed as a “high risk” for attempted suicide the year before he took his own life.

But it still hasn’t changed and a £5m program to upgrade all of REH’s single bedroom doors has yet to start – although the work is “urgent” by 2022.

Christopher, 30, is the primary caregiver for his mother, who has suffered from mental illness for decades.

He said: “My family have been waiting for four years to find out what happened that day.

“What I mean is that I handed this object to someone and there is no doubt that he planned to use this object to take her life. I trusted him to protect my mother, do the right thing and take care of her – and he didn’t do that.

“I took my mother there because I thought it would be a place where she would be saved and the day she died she was in more pain than when she went in.”

NHS Lothian has apologized to the family and is following up on complaints about Dr MacRae’s death. An internal review of the incident concluded that the manner in which the case was conducted “had a direct impact on the level of harm”.

The circumstances leading to Dr MacRae’s death at the Royal Edinburgh Infirmary are currently being considered at a fatal accident investigation (FAI).

However, BBC Scotland can reveal that:

• A safety briefing for staff working on Dr MacRae’s ward on the night of her death was not completed until four weeks after the incident.
• Ward staff did not know Dr. MacRae had previously tried to commit suicide
• The nurse admitted that it was an “error of judgment” not to take Christopher’s warning and evidence more seriously and not to search Dr MacRae’s room.

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

The 55-year-old was admitted to Royal Edinburgh Hospital as her mental health problems, which date back to the 1990s, have become acute.

Christopher, who sometimes visits his mother in the hospital twice a day, has a ritual where he promises to see her the next day.

“He got to the point where he felt he couldn’t fight anymore, he told me he was thinking about killing himself,” she said.

“For 26 years he always said: ‘Don’t worry, I’ll be here tomorrow, I’ll just spend the night’.

“That’s the first time he’s said no, I can’t promise to see you tomorrow – and that’s the hardest thing I’ve ever heard.”

Christopher said that his mother had shown him evidence that he wanted to kill himself.

He takes this to nurse Rado Rzeznicki, who says Christopher promises to search his room.

“To me, it seemed like if I didn’t do something, I was going to lose him,” he said.

“It never happened. My mother would still be with us now if she had cleaned her room and looked for the same object because, as it turned out, there was the same object in her room.

In evidence for the FAI at Edinburgh Sheriff Court earlier this month, Mr Rzeznicki said he took the evidence to the staff office, put it on the table and shared what he had told his colleagues.

However, he told the questioner that he could not remember who was there.

According to the review of serious adverse events NHS Lothian (SAER) to the incident, none of the nurses on duty can remember in the room when Mr. Rzeznicki passed this information – except for the most senior nurse, who also does not remember anyone else. there now.

The SAER, completed in 2020, found no details of whether Christopher’s evidence and concerns about his mother’s suicidal intentions were recorded in any NHS system or passed on verbally to those working the night shift when Dr MacRae died.

Mr. Rzeznicki told the FAI it was “an error of judgment” that he did not take Christopher’s danger more seriously and that “in retrospect I should have finished the search”.

The inquiry also heard that NHS Lothian had improved patient safety processes at the hospital since Dr MacRae’s death.

NHS Lothian’s SAER review also found that Dr MacRae’s previous attempts to end his life in the same way – one of which was at the same hospital where he died – were “not easily accessible in case records” and “unrecognized” by the medical team tasked with caring for him.

The review also revealed that a safety briefing prepared for nurses working on the ward on the night Dr MacRae died did not end the day as expected.

But the brief – a record of safety concerns that nurses previously thought they should have been aware of – was filled four weeks after Dr MacRae’s death “with no clear rationale for what was offered”, according to SAER.

Records of other clinical contacts between staff and Dr MacRae on the day of his death were filled in retrospectively by two nurses, SAER found.

Concerns about self-harm prevention measures at the Royal Edinburgh Hospital go back to an improvement notice given to the hospital by the Health and Safety Executive in 2015.

A 2017 NHS Lothian report then said it was accepted that the design for a part of the newly opened hospitalwhich included Dr MacRae’s ward, “disregarding the anti-ligature specifications required for the facility”.

A review into Dr MacRae’s death showed a risk assessment of the room carried out by a senior nurse in February 2019 described the door as “high risk” because of a ligature point.

SAER recommends door checks in all single bedrooms in REH acute wards.

NHS Lothian’s paper shows that a £5m door replacement program for the first hospital is proposed in 2022 and is considered “important due to the risk of patient suicide with the current doors”.

The work is still categorized as a priority.

NHS Lothian previously told BBC Scotland that a project to upgrade a door at Edinburgh Royal Infirmary is still ongoing due to budget constraints.

Dr Tracey Gillies, medical director at NHS Lothian said: “It is not appropriate to comment on ongoing legal proceedings, but we offer our condolences to Christopher and his family.”

• If you have been affected by the issues in this story, help and support is available through BBC Action Line.