Health board is to blame for suicides
NHS Tayside was fined £120,000 yesterday afternoon after three patients committed suicide at Perth’s Murray Royal Hospital.
The board, which lost £11.2m in 2019/2020, and is forecast to rack up a £5.6m deficit in the current financial year, admitted a catalogue of failings in its Moredum Ward.
During a two-hour plea in mitigation, Peter Gray, QC, for NHS Tayside, said the tragic consequences “shook the organisation to the core.”
That had subsequently led to a “root and branch” review which had led to “very radical improvements.”
He added: “It is a matter of profound regret and concern, in equal measure, that the organisation failed to meet the high standards which it sets in relation to the manegement of health and safety.”
He offered his “deepest sympaties” to each family for its tragic loss.
He highlighted “chronic staff shortages” at the ward where, at any one time, there were 50 per cent of the workforce off sick at one time.
That had led to reliance on agency staff.
There had also been no consultant psychiatrist dedicated to the ward, but that had been rectified, and other staff appointments had been made.
A standardised shift pattern had also been introduced.
Imposing the fine, Sheriff Lindsay Foulis noted that the ward, as frankly admitted by Mr Gray, had been working under an “alien and challenging environment.”
But he described the culpability on the part of the organisation was “high” - and it had been acceopted as being high.
The board had previously been described as “chaotic” and an earlier hearing and directly to blame for system failures which led to the deaths of Jodie McNab (22), Rebecca Sangster (31), and Jacqueline Proctor (60).
Jodie’s mother Tracy Swan said:
“Jodie was in a place of supposed safety when the events leading to her death occurred.
“Having learned of the health and safety failings within Moredun Ward at Murray Royal Hospital, we feel that she would have been safer at home with her family.
“It has taken almost seven years for Tayside health board to accept responsibility for the failings that led to Jodie’s death, and this has caused an enormous amount of stress and strain to us as a family.
“We would like to see changes within the mental health service provision in Tayside, and as a family we would dearly like to think that things have changed since Jodie’s death to prevent this happening to any other family.
“Sadly we don’t have any confidence that this is the case.”
In a rare criminal prosecution against a health board, the Crown outlined a series of failings which could have prevented the trio of deaths in the hospital’s Moredun Ward.
Fiscal depute Shona McJannett took two hours to read the 27-page narrative describing the psychiatric hospital’s failings over more than three years from its opening in 2012.
All three women were able to commit suicide on the ward by hanging themselves – after the board ignored previous recommendations and filled the rooms with unsuitable furniture.
Miss McJanett told Perth Sheriff Court: “Tayside health board failed Jodie McNab.
“Tayside health board failed Rebecca Sangster.
“Tayside health board failed Jacqueline Proctor.
“Time after time Tayside health board failed to follow its own procedure which required action to minimise the risk once identified.
“The risk existed for three and a half years and following the death of Miss McNab, Tayside health board failed to make changes which would likely have prevented the following deaths.
“One of the most effective ways to prevent suicide is to reduce access to the means of achieving that outcome.
“The risk of suicide is well known in healthcare. One of the primary means of tackling the issue is to identify and remove ligature points.
“The management of ligature anchor points by Tayside health board within the Moredun Ward was chaotic.”
Jodie had tried to kill herself previously.
The Crown said risks associated with a type of bed were know to the hospital when 52 new beds were ordered in 2012.
Numerous failed suicide attempts in little over a year were not properly recorded or reviewed.
In his report to HSE, Professor Kevin Gournay CBE of Kings College, said risk management was “chaotic” on the ward between 2012 and November 2015.
NHS Tayside admitted “failing to manage and control the risk of severe injury and death associated with ligature points” between 1 April 2012 and 4 November 2015.
NHS Tayside declined to comment. Rebecca’s mum Ann (63), has told how her family have launched an action for compensation at Edinburgh’s Court of Session.
Ann, from Abernethy, said: “I think if Murray Royal Hospital had been subject to regular inspections, then my daughter might still be alive today.”