HEALTH MATTERS: Health board admits failings over hospital suicide

Patient found unconscious in her room at Queen Elizabeth University Hospital

By Lucy Ashton

A health board has admitted failings after a woman killed herself in her room at Glasgow’s Queen Elizabeth University Hospital.

Anne Clelland, 49, who had a history of self harm, died awaiting a move to a mental health facility in May 2015.

Glasgow Sheriff Court heard this was a result of a “communication failure”.

NHS Greater Glasgow and Clyde admitted failing to conduct itself in a way “that a person would not be exposed to risks to their health and safety”.

The board expressed its deepest sympathies to Ms Clelland’s family.

Ms Clelland was admitted to Queen Elizabeth University Hospital on 7 May, 2015, after a suicide attempt.

She was deemed medically fit to leave on Friday 15 May and a psychiatrist reviewed her.

Plans were put in place for her to be transferred to Leverndale mental health hospital in Glasgow.

The court heard the psychiatrist believed there was significant ongoing risk of harm, and put in place arrangements for Ms Clelland’s transfer despite no beds being available.

Prosecutor Catriona Dow said: “There appears there was a breakdown in communication regarding the intention of the psychiatrist that Anne would be transferred that evening due to her assessed risk of self-harm.”

The court heard that witnesses recalled a transfer plan, but it was understood that until a bed was to become available Ms Clelland was to remain at QEUH over the weekend.

Ms Dow added: “No one on duty over the weekend were aware of the assessment that she was at risk of self-harm.

“They did not appreciate the need to transfer Anne for this reason.”

Ms Clelland was found unconscious in the toilet of her hospital room on Monday 18 May. She was pronounced dead the next day.

A post mortem determined the cause of death as “brain injury due to hanging”.

An investigation found there was a “lack of clear and consistent understanding of Anne’s risk of self-harm and suicide”.

It was also accepted that “staff did not appreciate that Anne was at a significant risk of self-harm and consequently there was no ligature point risk assessment or observations”.

The court heard that following Ms Clelland’s death, there is now a more robust transfer procedure and rooms at the hospital are more suitable for patients in similar circumstances.

Vinit Khurana QC, defending, said it was “a matter of deep regret” that Ms Clelland could kill herself “as a result of the organisation’s failings.”

He added: “I am instructed to express the board’s deepest sympathies to her family. This was not a deliberate breach and wasn’t symptomatic of other failings.

“This was an organisation trying its very best to protect patients and it was a failure of communication on that single day which had tragic consequences.”

The court also heard that NHS Greater Glasgow and Clyde had previous convictions over the suicide of three other patients.  Sentence was deferred until later this month.

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