25th June 2020

Environment ‘Unsafe’ staffing factor in psychiatric patient’s death

Environment ‘Unsafe’ staffing factor in psychiatric patient’s death


environment Royal Edinburgh HospitalImage copyright

Image caption

Clare Shannon was a patient at the Royal Edinburgh Hospital when she died

“Unsafe” staffing levels on a hospital psychiatric ward contributed to the death of a patient who took her own life, a sheriff has concluded.

Clare Shannon,30, died by suicide in April 2014 at the Balcarres Ward in the Royal Edinburgh Hospital.

Two staff on duty that night were looking after 20 patients, at least one of whom needed constant supervision.

A fatal accident inquiry (FAI) found staffing was “inadequate” and a factor in Ms Shannon’s death.

NHS Lothian said it accepted the findings and had made “significant changes” to its ways of working since the death.

An earlier hearing at Edinburgh Sheriff Court heard that Ms Shannon had spent many years suffering from Emotionally Unstable Personality Disorder.

In 2007 she made a short film “Unwell” about what it was like to be constantly hearing voices in your head, and had made repeated attempts on her life in the years leading up to her death.

Sheriff Wendy Sheehan, who presided over the FAI, wrote: “There was a defect in the system of work on the Balcarres ward, Royal Edinburgh Hospital, which on April 4 2014, allowed two nursing staff (one of whom was a nursing assistant with no formal qualifications and less than a year’s experience) to care for 20 acutely unwell patients (at least one of whom required constant observation and others who had a propensity to self-harm).

“This was unsafe and contributed to the accident resulting in Clare Shannon’s death.”

Sheriff Sheehan said that a “reasonable precaution” which could have been taken to avoid Ms Shannon from losing her life was to ensure that she was “directly observed” when using the toilet “at all times”.

Environment New guidance

The judgement also stated that Ms Shannon may have not received the most appropriate care whilst a patient at the Balcarres Ward.

Sheriff Sheehan said this was because the ward was designed for caring for acute patients and not people with long term conditions like Ms Shannon.

She said NHS Lothian needed to do more to develop services to help people who may have similar needs to Ms Shannon, including recommendations issued last year by Healthcare Improvement Scotland (HIS) entitled “From Observation to Intervention”.

She wrote: “Acute wards, by their nature, do not provide an environment where patients with serious, chronic conditions may receive specialist clinical psychology treatment to address their core psychopathology.

“Acute wards are also not designed to provide the safe, therapeutic and intensive care environment, length of admission or staffing ratios which patients undergoing such treatment require.

“The introduction of the 2019 guidance in all NHS Lothian adult inpatient psychiatric wards might realistically prevent other deaths in similar circumstances.”

Dr Tracey Gillies, medical director of NHS Lothian, said: “We accept the findings and the recommendations in Sheriff Sheehan’s report.

“We have already made significant changes to the ways of working within the hospital, to staffing levels, which we keep under review and to the investment in the therapeutic environment within the new Royal Edinburgh Hospital.

“In addition we are implementing the 2019 HIS observation standards.”


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