Dr Sara Lilian Macrae

(i) When staff in a secure mental health ward are presented with evidence that a patient has vocalised suicidal ideation and demonstrated means to complete suicide by presentation of a ligature, urgent action to search that patient's room and person for any other potential ligatures ought to be taken. In addition, consideration should be given to placing the patient on constant observations or invoking a Clinical Pause to evaluate the safety issues which exist and produce a plan of intervention to address the issues identified. (ii) The medical records of a patient should be accessible across different Health Boards regardless of the Health Board in which that patient is treated to ensure the treating Health Board has the patient's full medical history available to inform fully the most appropriate care and treatment plan for the patient. (iii) Meaningful implementation and ongoing audit (including external audit of the person centred audit tool) of the Serious Adverse Event Review action plan relating to Dr Macrae's death should continue. (iv) TRAK should be developed to introduce a function to alert clinicians to potential risk factors such as previous suicide attempts as soon as they open the patient's notes.