Suicide of psychiatrist in hospital could have been avoided, inquiry finds
The death of a psychiatrist who took her own life while a patient in hospital could have been avoided, an inquiry has found.
Dr Sara Macrae died on March 17, 2020 while she was a patient in the Royal Edinburgh Hospital.
The 55-year-old, who had a long history of psychotic disorder complicated by alcohol misuse, had been admitted to the hospital on February 5 as a result of concerns about her mental health.
In the ensuing weeks, her medical notes recorded a number of instances of “suicidal ideation”, and also that her mental state “started to deteriorate” in the week leading up to her death on March 17, a fatal accident inquiry (FAI) found.
Her son Christopher also notified the hospital on multiple occasions that his mother had told him she was going to take her own life, including during visits to her on March 17 in the hours before she died.
He was assured by staff they would carry out a search of her room, and also that they would “check in on Dr Macrae and make sure she was all right”.
In her determination published following the FAI into Dr Macrae’s death, Sheriff Alison Stirling found there were reasonable “precautions” that could have been taken that might have resulted in her death being avoided.
Following Dr Macrae’s death, a serious adverse event review was carried out... The output of this was an extensive improvement action plan, which has been worked through and audited
These included putting Dr Macrae under constant observation, and the recording of more information about her condition, including her “voiced suicidal ideation”, in her medical records and weekly reviews.
The report also said details of a previous attempt by Dr Macrae to take her own life at the same hospital were not “easily accessible” in her medical notes, something it described as a “defect in the system of working” at the hospital that “contributed” to her death.
Following the publication of the sheriff’s determination, procurator fiscal Andy Shanks, who leads on fatalities investigations for the 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 FAI.
“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.”
The FAI was instructed by the Lord Advocate as she considered Dr Macrae’s death had occurred in circumstances giving rise to serious public concern.
Dr Tracey Gillies, medical director at 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.”