Guilty...healthofficials admit ‘series of failures’ over deaths of 3 patients
A HEALTH board has admitted criminal responsibility for the deaths of three patients in a single ward at one of its hospitals.
Failings over several years led to the deaths at the new PFI-funded Murray Royal Hospital in Perth.
NHS Tayside was described as ‘chaotic’ and directly to blame for the deaths of Jodie McNab, 22, Rebecca Sangster, 31, and Jacqueline Proctor, 60.
In a rare criminal prosecution, the Crown outlined failings which could have prevented the deaths in the hospital’s Moredun ward.
It took fiscal depute Shona McJannett two hours to read the 27-page narrative describing the psychiatric hospital’s failings over three years, from its opening in 2012.
All three women committed suicide by hanging – after the board ignored recommendations about unsuitable furniture.
Ms McJannett told Perth Sheriff Court: ‘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.
‘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.
‘One of the primary means is to identify and remove ligature points. The management of ligature anchor points within the Moredun ward was chaotic.’
Miss McNab took her own life in 2013 using a type of bed which the hospital had been told was unsafe in an acute psychiatric ward.
Ms McJannett said a fatal accident inquiry attended by NHS Tayside several years earlier found that a man had hanged himself from a ‘King’s Fund’ traditional bed. She said: ‘The risk associated with ligature anchor points on the beds was known to the health board since 2009, if not before.
‘Despite this, in April 2012, 52 new King’s Fund beds were purchased for use in Moredun ward.
‘It is not known why Tayside Health Board ordered unsuitable beds. When the ward opened, NHS Tayside did not consider the risks.’
One safe divan-style bed was bought, and management said a programme of replacement should be put in place.
But Ms McJannett said: ‘The programme was not prioritised, not managed, and entirely ineffectual. Two-and-a-half years after Miss McNab’s death... the [King’s Fund] beds remained in 20 bedrooms.’
There were numerous failed suicide bids on the ward and it was clear that wardrobe and bathroom doors could be used in hangings.
Ms McJannett said: ‘A second environmental risk assessment was not carried out prior to the deaths of Rebecca Sangster and Jacqueline Proctor.
‘Failures to deal with ligature risks does not appear to be attributto able to any one individual but rather the management of risks was neglected.’
Magnetic doors which were not weight bearing were identified as a solution in 2013, but again no action was taken in the two years before the other women died.
Ms McJannett said: ‘NHS Tayside failed to identify and manage the risk associated with the weight bearing nature of wardrobe and bathroom doors.
‘The wardrobe doors were not suitable and NHS Tayside failed Rebecca Sangster by their failure appropriately assess and remove them. She was able to use them in the course of her death.
‘Tragically, just over a week later, Jacqueline Proctor was able to create a ligature point.
‘The ligature anchor points associated with these doors was known to NHS Tayside at director level since 2013, but no remedial action was taken. The removal and management should have been a priority for the Health Board.’
NHS Tayside admitted ‘failing to manage and control the risk of severe injury and death associated with ligature points’ between April 1, 2012, and November 4, 2015. Sentence is expected this week.
Miss McNab attended Perth College and was keen on a career supporting children’s mental health.
Her mother, Tracy Swan, said: ‘Words cannot express how much we miss her. We have been particularly devastated to learn that not only could Jodie’s death have been prevented, but that recommendations had been made following a similar death which meant all beds within the ward should have been replaced before Jodie’s death.’
Ms Sangster was the middle of four children and very close to her twin brother. Ms Proctor, a talented artist, was a support worker with Plus Perth, a charity assisting people with mental health problems.
‘Words cannot express how much we miss her’