Investigation after third suicide at NHS Ayrshire and Arran hospital
An investigation is taking place after a patient hanged himself at a hospital’s accident and emergency department.
The health authority and the police are investigating the death at University Hospital Ayr, situated south-west of Glasgow.
A hospital spokesperson said: “NHS Ayrshire and Arran is aware of an incident that took place at University Hospital Ayr on August 8.
“In line with our policies and procedures we are carrying out the relevant investigations alongside Police Scotland. It would not be appropriate for us to comment further.”
A spokesperson for Police Scotland said: “Police can confirm the body of a 42-year-old man was found at Ayr Hospital on August 8. The death is not being treated as suspicious and a report will be sent to the Procurator Fiscal.”
This is the third suicide to have happened at an NHS Ayrshire and Arran hospital in recent years.
In 2010, two patients committed suicide at University Hospital Crosshouse, in Ayrshire on the same day. NHS Ayrshire and Arran was prosecuted by the Health and Safety Executive in both cases.
On 31 August 2010, Gary Niven, 42, had called an ambulance to his house saying he was feeling suicidal.
He was known to have a history of depression and intractable cluster headaches. He was taken to Crosshouse Hospital where he was taken to a room beside the main staff base with the door left open.
In an article for the Guardian from 2013, Gary’s brother John explains how Gary managed to close the door to his room and hang himself.
He was resuscitated, but suffered severe hypoxic brain damage and died on 3 September 2010.
NHS Ayrshire and Arran pleaded guilty to sections 3 and 33(1)(a) of the Health and Safety at Work etc Act 1974 for failing to ensure the health and safety of people not in its employment, and were fined £67,000.
The HSE found that NHS Ayrshire and Arran had identified the risks of psychiatric patients being left alone – and by implication self-harming – and had procedures in place but that these had not been followed.
On the same day, another patient, Nicola Black 33, hanged herself at Crosshouse Hospital the day after she was admitted to a mental health ward for care and treatment.
She had been assessed by a doctor as being at high risk of suicide, self-harming and absconding from her room, and as a result was to be kept under constant observation.
However, despite this she died after she used her bootlaces as a ligature, attached to a window restrictor, which was secured to the top of the window of her hospital room.
The HSE carried out an investigation which found a number of failings:
- Restrictors, which stopped windows from opening more than 10cm to prevent absconding and falls, were at risk of being used as a ligature point. A contractor had been asked to remove them from the hospital’s mental health wards but there was no record of the work being completed or any check carried out of the work.
- Despite Ms Black needing to be under constant observation, the three healthcare assistants tasked with this had only been told that the patient was at risk of absconding and were not aware of the suicide risk.
- Part of the patient’s room could not be seen by the assistants. When Ms Black was out of sight, the assistants looked in and saw her standing in the corner. At some point after they looked in and found her hanging.
- There was no policy or procedure in place for checking and removing personal items (in this case boot laces) that might be used as a ligature, when admitting patients to the ward.
Following the investigation, NHS Ayrshire and Arran Health Board was fined £50,000 after pleading guilty to breaching section 3(1) of the Health and Safety at Work etc Act 1974.
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