Doctor died on psychiatric ward hours after son warned staff of suicidal thoughts

The death of a doctor at a secure psychiatric hospital in Edinburgh could have been prevented if her son’s warnings about her suicidal ideations had been acted on, a sheriff has ruled.

Dr Sara Lilian Macrae, 55, died on the Craiglockhart Ward at Royal Edinburgh Hospital on March 17, 2020, hours after her son had presented medical staff with evidence that she was planning to take her own life.

Dr Macrae, a psychiatrist who had been diagnosed with schizo-affective disorder, was admitted to the hospital on February 5 before a compulsory treatment order was made on March 10.

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A Fatal Accident Inquiry into her death found that Christopher MacRae had warned a staff member that his mum had spoken of her plans to take her own life and shown him an item she was planning to use.

He took the item and gave it to nurse Radoslaw Rzeznicki before pleading with him to clear Dr Macrae’s room of any other dangerous items.

As visiting time ended, Mr MacRae noted that his mum was “much more” distressed than usual and had been unable to promise that she would see him the following day.

A member of staff reassured him, telling him that she would check on Dr Macrae to make sure she was alright.

Dr Sara Macrae died in March 2020. STV News

A short time later, Mr MacRae called the ward in the hopes that his voice would calm his mum down, but he received no response.

He was informed less than two hours later that his mum had taken her own life.

The inquiry found that a search of the patient’s room was never carried out and that nurse Rzeznicki assessed that Dr Macrae would not act on her ideations, resulting in her observation level not being increased.

Nurse Rzeznicki told the inquiry that he had failed to appreciate the importance of what Mr MacRae had told him and that he should have taken the item and the concerns of the family more seriously.

He had also not recorded the discussion with Mr MacRae in the patient’s notes.

‘Inadequate care’

Consultant forensic psychiatrist Dr Khuram Khan found that Dr Macrae had received “inadequate” care when admitted to the hospital on February 5.

He raised issues surrounding the fact that there had been no mention of suicidal risk assessment or management and that staff had not been made aware of her previous attempts.

There was also no record of Mr MacRae handing in the item given to him by his mum on the day of her death.

Dr Khan concluded that if observation levels had been increased to constant observation and if her room had been searched, it was “more likely than not” that her death could have been prevented.

Dr Sara Macrae with her son Chris STV News

A safety brief of the day of Dr Macrae’s death – to help provide up-to-date information about patients, which might help safeguard them by highlighting changes in behaviour – was not completed until four weeks after.

‘High risk’ doors never replaced

NHS Lothian has since ordered a Significant Adverse Event Review (SAER) into the circumstances surrounding Dr Macrae’s death.

Among its findings were that expressions of suicidal intent must be recorded, and a review should be carried out on the process of handover for information and concerns within and between shifts.

It was also ordered that a review of the design of the rooms on all single bedrooms within Royal Edinburgh Hospital’s acute wards should be carried out.

It comes after an inspection of Dr Macrae’s bedroom carried out a year before her death had found that the door presented a “high risk” for suicide attempts.

The inquiry heard that despite staff reports to NHS Lothian, there has been no door replacement across the health board’s estate to address the “urgent” requirement.

Sheriff’s ruling

In her ruling, Sheriff Alison Stirling concluded that observations should have been increased, a search should have been carried out of Dr Macrae’s room and that a suicidal risk assessment should have been recorded weekly.

The sheriff also found that entries in Dr Macrae’s medical notes of a previous suicide attempt by similar means in the same hospital were not “easily accessible”.

It was recommended that a system should be developed to introduce a function to alert clinicians to potential risk factors such as previous suicide attempts as soon as they open the patient’s notes.

It was concluded that there were precautions which could reasonably have been taken and had they been taken they might realistically have resulted in the death being avoided.

Dr Macrae’s family said the Sheriff’s determinations highlighted the failings which contributed to her death.

“We welcome Sheriff Stirling’s determination which highlights in stark terms the scale of individual and system-wide failings within the Royal Edinburgh Hospital and NHS Lothian that contributed to Sara’s death,” they said in a statement.

“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.”

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.”

Following the publication of the determination, procurator fiscal Andy Shanks, who leads on fatalities investigations for COPFS 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.” 

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