A woman who died by suicide at a hospital was assessed without knowledge of previous attempts to end her own life.
26-year-old Kerry Ann Finnigan died by suicide on December 21, 2019, at University Hospital Wishaw, where she was admitted four days before.
A Fatal Accident Inquiry has concluded that some precautions "might realistically have resulted in the death being avoided".
On arrival, the English Literature graduate was assessed as high-risk and requiring special observations but was then re-examined on December 19 and labelled as low risk.
The FAI stated that the risk assessment was carried out without access to the Multi-Disciplinary Information System (MiDIS), which contained Ms Finnigan's electronic medical records.
Sheriff Colin Dunipace added that the decision was also made without information about her previous suicide attempts, contained in her discharge letter from University Hospital in Monklands, where she was previously treated.
The sheriff continued: "Significantly, senior charge nurse Cochrane undertook this assessment without knowledge of, and therefore without reference to, Ms Finnigan’s multiple suicide attempts whilst in Monklands Hospital only 48 hours before.
"It was clear from the evidence that Nurse Cochrane did not take these incidents into account when completing her risk assessment."
He referred to these pieces of information as "clearly extremely significant factors" in the decision to reduce Ms Finnigan's risk factor.
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The FAI also read that the change was made before the patient met with her doctor at University Hospital Wishaw and without knowledge of the terms of the Short-Term Detention Certificate (hereinafter “STDC”).
Ms Finnigan was then assessed at medium risk on December 20, 2019, again "without access to the significant information regarding the recent suicide attempts".
Sheriff Dunipace said: "The decision to reduce the observation level from “constant” to “general” was a matter which may have directly contributed to Ms Finnigan’s death.
"Had the nurse who reduced the observation level and the doctor who ratified that decision been aware of the recent previous history of self-harm in Monklands Hospital, then a reasonable precaution would have been to keep Ms Finnigan’s observation level as constant until a discussion could take place regarding these previous attempts at suicide and a safety plan put in place, with that decision being reviewed by a consultant psychiatrist."
The paper made five recommendations to NHS and NHS Lanarkshire following the investigation, including that all patients admitted to a psychiatric ward in NHS Lanarkshire should be reviewed by a senior clinician within 24 hours of admission and a review of their policy to ensure sufficient oversight of patients with mental health issues being treated within a medical setting.
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