Psychiatric patient found dead after unescorted walk

The patient was found dead in the grounds of the the Royal Edinburgh Hospital. Picture Ian Georgeson
The patient was found dead in the grounds of the the Royal Edinburgh Hospital. Picture Ian Georgeson
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A PSYCHIATRIC patient who was handed a pass to walk unescorted in the grounds of the Royal Edinburgh Hospital was found dead two weeks after he went missing.

Health bosses have been criticised in an ombudsman’s report over the decision to give the man a pass and the failure of staff to report him missing until two hours after he had been expected to return.

The patient, identified only as Mr A, had been admitted to the hospital after an 
apparent suicide attempt. He was granted unescorted time to walk in the grounds on March 5, 2012. Excursions beyond the grounds were only to take place with an escort.

Mr A did not return when expected, but staff decided not to contact police to report him missing until some two hours later. He was found dead outwith the hospital on March 19.

Mr A’s fiancée complained that NHS Lothian had not provided reasonable care and did not involve her in decisions about his treatment.

Her complaints have now been upheld by the Scottish Public Services Ombudsman (SPSO), who concluded it had been unreasonable to grant Mr A an unescorted pass and said staff failed to act with “sufficient urgency” when he disappeared.

The ombudsman said: “Although it cannot be concluded that these failures led directly to Mr A’s death, they represent a significant failing on the part of the board.”

An internal review by NHS Lothian found there had been “clear cause for concern” in the days leading up to Mr A’s disappearance and noted that at least one member of staff had strongly felt he should not have been given a pass.

But the review concluded that although the decision to issue the pass was high-risk, the professional judgment of staff was reasonable. It also said it was reasonable not to contact police sooner.

NHS Lothian has already apologised to Mr A’s fiancée and the ombudsman made a series of recommendations on improving procedures.

Dr David Farquharson, medical director, NHS Lothian, repeated the board’s apology to the family of Mr A and said changes had been made to the system of patient passes and carer involvement to prevent similar incidents in the future.