NHS apologise to son of woman who took own life in hospital hours after plea for help

Christopher with his mum Dr Donna MacRae
-Credit: (Image: Chris MacRae)


The NHS has issued an apology after staff failed to do anything after a son warned his mother was planning to take her life in hospital.

The heartbroken son of former psychiatrist Dr Sara MacRae said he gave a nurse “clear evidence” that his mum planned to commit suicide just hours before she died at at the Royal Edinburgh psychiatric hospital (REH) in March 2020.

Christopher handed evidence he had found to the staff member and pleaded with him to search his mum’s bedroom for more potential dangers. However the search was not carried out and Dr MacRae was later found dead in her room.

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Christopher said his mother had shown him evidence that she intended to kill herself and passed on the information to nurse Rado Rzeznicki. He said he promised he would search her room.

Speaking to the BBC, he said: "To me, it seemed like if something wasn’t done about that I was going to lose her.

“It never happened. My mum would in likelihood still be with us today if he had cleared her room and looked for any similar objects because, as it turned out, there was a prominent similar object in her room.”

Dr Donna MacRae suffered mental health problem for several decades
Dr Donna MacRae suffered mental health problem for several decades -Credit:Chris MacRae

The 30-year-old said his mum had suffered mental illnesses since the 90s. She had been diagnosed with schizoaffective disorder and had been in hospital for six weeks before her death.

Christopher was his mum's main carer. He added: “My family has been left in the dark for over four years waiting to find out what actually happened on that day.

“What I do know was that I handed this object to someone and there was no doubt she planned to use this object to take her life. I trusted him to protect my mum, to do the right thing and take care of her - and he didn’t.

“I took my mum there because I thought that was going to be the place where she was going to be saved and the day she died she was more unwell than on the day she went in.”

Christopher said he would sometimes visit his mum at the hospital twice a day. He added: “She reached a point where she felt she could no longer fight, she told me she was considering taking her own life.

“For 26 years she always said: ‘Don’t worry I’ll be here tomorrow, I’ll just get through the night’.

Christoper with mum Donna when he was a young boy
Christoper with mum Donna when he was a young boy -Credit:Christopher MacRae

“This was the first time she had said no, I can’t promise I’ll see you tomorrow - and that was the hardest thing I’ve ever heard.”

NHS Lothian has since apologised to the family and said they were now improving their processes for identifying patient risks.

The BBC reports the door in 55-year-old Dr MacRae’s room had been assessed as a “high risk” for suicide attempts the year before she took her own life, however they claim it it has still not been replaced. A £5m programme to upgrade all the REH’s single bedroom doors has not yet started - despite the work being described as “urgent” in 2022.

An NHS Lothian internal review of Dr MacRae's death concluded that the way the case was managed “had a direct impact on the level of harm”. They upheld the family's complaint. The circumstances around her death is now being considered at a fatal accident inquiry (FAI).

In evidence to the FAI at Edinburgh Sheriff Court earlier this month , Mr Rzeznicki said he took the evidence into a staff office, put it on a table and shared what he had been told with colleagues.

However, he told the inquiry he could not recall who was present.

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”.

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.

The review into Dr MacRae’s death revealed a risk assessment of her room carried out by senior nurses in February 2019 described the doors as “high risk” because of the presence of ligature points.

The SAER recommended a review of the doors in all single bedrooms in the REH's acute wards.

Dr Tracey Gillies, medical director at NHS Lothian said: “It would be inappropriate to comment on an ongoing legal process, but we extend our sincere condolences to Christopher and his family.”

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