Son gave hospital ‘clear evidence’ his mum planned to take her own life

According to NHS Lothian’s serious adverse event review (SAER) into the incident, none of the on-duty nurses could recall being in the room when Mr Rzeznicki passed on this information – apart from the most senior nurse, who also could not remember who else was present.

The SAER, completed in 2020, found no details that Christopher’s evidence and concerns about his mum’s suicidal intentions were recorded in any NHS systems or passed on verbally to those working on the night shift when Dr MacRae died.

Mr Rzeznicki told the FAI it was his “error of judgement” not to take Christopher’s warnings more seriously and that “in retrospect I should have done the search”.

The inquiry also heard that NHS Lothian had improved its patient safety processes in the hospital since Dr MacRae’s death.

NHS Lothian’s SAER review also found that previous attempts by Dr MacRae to end her life by a similar method – one of which was in the same hospital where she died – were “not readily accessible in the case notes” and “not known” by the team of medics charged with looking after her.

The review also revealed that a safety briefing which was meant to be prepared for nurses working on the ward the night Dr MacRae died was not completed that day as expected.

Instead the briefing – a note of any safety issues that the previous shift of nurses thinks colleagues should be aware of – was filled in four weeks after Dr MacRae’s death “with no clear rationale for this offered”, according to the SAER.

Other clinical records of contact between staff and Dr MacRae on the day of her death were filled in retrospectively by two nurses, the SAER found.