A pensioner who was found dead hours after he left a psychiatric facility may have lived if nurses told doctors about his suicidal thoughts, a sheriff has concluded.
Mountain Rescue team members found the remains of William Clark (66) at Kinnoull Hill in Perth on July 24 2016, a Fatal Accident Inquiry at the city’s sheriff court heard.
Sheriff Keith O’Mahony heard how Mr Clark had been a patient at the Leven Ward at the Murray Royal Hospital in Perth.
He had been admitted there in May 2016 after becoming unwell. He told a consultant psychiatrist that he did not wish to “wake up” but had no plans to take his life.
However, on July 22 2016, Mr Clark, also of Perth, asked a nurse for a gun and made a gesture as if he was going to shoot himself.
The inquiry heard that the following day, staff thought Mr Clark ‘presented’ to them as he usually did.
However, he later walked out of the hospital and later died from sustaining ‘blunt force’ injuries from ‘falling’ at the hill.
At the inquiry, consultant psychiatrist Neil Prentice told Sheriff O’Mahony that nursing staff should have told the duty doctor at the facility about Mr Clark’s desire to obtain a gun.
He said this may have led to a doctor examining Mr Clark and devising a plan which may have kept him alive.
In a written judgement issued on Monday, Sheriff O’Mahony said he agreed with Dr Prentice’s submissions.
Sheriff O’Mahony wrote: “It was the view of Dr Prentice that given the events of July 22 2016 he would have expected nursing staff to contact the duty doctor to have Mr Clark examined.
“He regarded the comments made by Mr Clark in relation to a gun as being a change in Mr Clark in that they represented a new and violent idea.
“Previously he had had negative ideas but now had expressly made reference to a violent method.
“I am satisfied in those changed circumstances that arrangements should have been made to contact the on-call doctor with a view to a fresh medical examination of Mr Clark’s condition and a renewed risk assessment.
“The evidence demonstrated that could have been carried out the following morning, i.e. the morning of July 23, 2016.
“I cannot, of course, say what the outcome of that examination and assessment would have been. I heard evidence that there would have been a range of possible different outcomes, including mandatory detention in terms of the legislation and/or a “locked door”policy being implemented in respect of Mr Clark.
“The test imposed by the legislation is whether such a precaution ‘might realistically’ have resulted in the death being avoided. I am satisfied that test is met.”
Evidence in the inquiry was heard at Perth Sheriff Court last year.
The judgement tells of how Mr Clark’s first documented contact with NHS psychiatric services was in 1991 when he was aged 41. He sought help for poor mental health on a number of occasions throughout the years.
The inquiry heard that in January 2016, Mr Clark’s wife was admitted to hospital in Dundee and he started to struggle day to day tasks.
He met his GP in May 2016 and the medic concluded that Mr Clark was severely depressed and was having “fleeting” suicidal thoughts. He was later admitted to the Leven Ward at the Murray Royal Hospital. Mr Clark told staff he did not have “the bottle” to take his life.
Mr Prentice was in charge of his care. He changed his medication and Mr Clark remained as a patient there until July 2016.
After Mr Clark expressed a desire to obtain a gun, staff gave him a sedative. Ligature risks were also removed from his room.
Staff also decided to check on him every 15 minutes - however, these quarter hourly checks were removed on July 23.
,Police were contacted at 8.35pm. CCTV evidence showed that Mr Clark left the hospital at around 7.20pm.
On July 24 2016, Mr Clark’s body was found around 30 metres from the cliff at the hill.
Sheriff O’Mahony said that nursing staff did not record their assessment of Mr Clark’s behaviour on July 22.
He also said staff did not record their reasons for reducing their checks on Mr Clark.
He wrote: “I also observe that the nursing clinical assessment of Mr Clark’s behaviour on the evening of July 22 was not recorded. “Nor was the rationale for reduction in checks on July 23 or the rationale for the removal of ligatures.
“These are adminicles of information that should have been recorded.”
But Sheriff O’Mahony said that if these steps had been taken, it would not have resulted in a guarantee that Mr Clark could have survived.
He wrote: “However, there is no evidence that the failure to do so resulted in a different path being taken as regards Mr Clark.”
A spokesperson for NHS Tayside said: “Our thoughts remain with the family and we will now take time to consider the sheriff’s determination.”
