A pensioner found dead hours after he left a psychiatric facility might have lived if nurses had told doctors about his suicidal thoughts, a sheriff has concluded.
The remains of William Clark, 66, were found by mountain rescue workers at Kinnoull Hill in Perth on July 24 2016, a fatal accident inquiry at the city’s sheriff court was told.
Sheriff Keith O’Mahony was told that Clark had been a patient at the Leven ward at the Murray Royal Hospital in Perth. He was admitted in May 2016 and had told a consultant psychiatrist that he didn’t wish to “wake up”, but had no plans to take his life.
However, on July 22, 2016, he asked a nurse for a gun and made a gesture as if he was going to shoot himself. The inquiry was told that the following day, staff thought Mr Clark was behaving as he normally did. However, he later walked out of the hospital and died after “falling” at the hill.
Neil Prentice, a consultant psychiatrist, told the sheriff that nursing staff should have informed the duty doctor at the facility about Clark’s desire to obtain a gun. He said this may have led to a doctor examining Clark and devising a plan which might have kept him alive.
Advertisement
In a written judgment O’Mahony said he agreed with Dr Prentice’s submissions and he would have expected nursing staff to have contacted the duty doctor for an assessment. He said that he could not know what the outcome of the assessment would have been but could have included a mandatory detention or “locked door” policy being implemented for Clark. He wrote: “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.”
Clark’s first documented contact with NHS psychiatric services was in 1991 when he was aged 41. In January 2016, his wife was admitted to hospital in Dundee and he started to struggle.
After 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, but these checks were removed on July 23, the same day that he went missing.
The sheriff said that nursing staff did not record their assessment of Clark’s behaviour or reasons for reducing their checks, but added that if these steps had been taken, it would not necessarily have meant Clark would have survived.