Recommendation 1

All patients admitted to a psychiatric ward within NHS Lanarkshire should be reviewed by a senior clinician within at least 24 hours of admission, a policy, which has been seen to work successfully in other NHS areas such as NHS Grampian. Such a policy would ensure that admitted patients to hospital would have a senior clinician review within 24 hours, thereby enabling a senior clinician to formulate clear plans for that person which can then be followed until a RMO attends the ward. This level of oversight from an approved medical practitioner at the beginning of admission would have alleviated some of the issues outlined above.

Response

There are 15 ward areas across NHS Lanarkshire’s Mental Health, Learning Disability, and Addictions services estate comprising General Adult Psychiatry, Older Adults Psychiatry, Learning Disability Psychiatry and Forensic Psychiatry. 

In 2024, NHS Lanarkshire undertook a review of their model of inpatient/outpatient psychiatry, including cognisance of; national workforce pressures in psychiatry, the extant medical literature and engagement with practitioners, stakeholders and service users to understand the pros and cons of the traditional model of in-patient psychiatry. The traditional model is whereby patients from a geographical area, for example, one of our localities, have the same designated senior psychiatrist whether an in-patient or outpatient. For longer term patients, this is typically throughout their journey from their community and their ward setting if they are admitted and back again. The traditional model offers valuable continuity for patients across their journey but does mean that individual consultant psychiatrists have to split their time between the ward and communities they cover. This can result in a patient’s designated psychiatrist attending the ward on only certain days of the week as described in this FAI. Thus, in the traditional model, the duty approved medical practitioner contribution, senior resident doctor’s review and senior registered mental nurse reviews support in-patients when the designated psychiatrist is undertaking outpatient work, such as, home visits, clinics and multi-disciplinary meetings or attending to Mental Health Act work.  

As a result of the review undertaken in 2024, in North Lanarkshire General Adult Psychiatry wards the model has been changed away from the traditional model. The new and current model is such that there are consultant psychiatrists dedicated solely to inpatient work and others solely to outpatient work. This means that the medical care of patients admitted to these wards transfers wholly from doctors in the community or doctors in other inpatient areas, such as medical wards, to the ‘in patient’ psychiatrists. 

As part of our planning for this change, a new post was created of ‘Clinical Director In-Patient Psychiatry’. The new clinical director appointed in February 2025 has overseen the transition to the new model in North Lanarkshire General Adult Psychiatry wards, which was completed in June 2025; and is responsible for ensuring there are well governed and safe protocols and operating procedures in place for in patients and for transitions in and out of psychiatry wards. As such, the ‘in-patient’ consultant psychiatrists would review newly admitted patients within 24 hours in line with the recommendation made. Subsequent to the North Lanarkshire wards test of change above, discussions have begun to start the process of change with South Lanarkshire General Adult Psychiatry wards, with a timeline of one year for piloting this work, with a test of change to start by April 2027.

Learning Disability Psychiatry and Forensic Psychiatry already have dedicated in-patient psychiatry support daily. The Older Adults Psychiatry service has recently submitted a proposal to mirror the General Adults new model with additional consultant input into the Older Adults ward areas. 

These measures alone are not enough to entirely fulfil the recommendation of the FAI. For in-patient admissions out of hours, within the working week, the above provisions will apply. Over the weekend out of hours, discussions have been initiated with staff side medical workforce representatives to allow for the changes in working practice that would lead to senior medical staff reviewing all newly admitted patients out of hours within 24 hours. This links with recommendation five and the role of the Approved Medical Practitioner as General Adult Psychiatry wards would also have the potential provision of duty Approved Medical Practitioners to support this recommendation.

Finally, given the senior clinical level of skill and knowledge of Advanced Nurse Practitioners in Mental Health there is the potential for increasing ANP input into inpatient ward areas, including for this purpose. Discussions within the service and with Advanced Nurse Practitioners have commenced.

Recommendation 2

All Goelst G‐Rail 4100 Load Release System Curtain Rails that are currently in operation within NHS Scotland should be replaced with alternative models. While it has not been possible to definitively resolve the exact reason why this shower rail failed to collapse in the present case, it is likely that it did so because the weight attached to it was not applied vertically allowing the fitting to be used as a ligature point. The fact that it did not and Ms Finnigan was able to use it to complete suicide demonstrates that the system presented a danger in itself, and it was noticeable that the previous an Estates and Facilities Alert (hereinafter referred to as “EFA”) issued in March 2019 identified a similar failure to collapse on a number of occasions when weights were applied at an angle. Patients admitted to psychiatric wards are some of the most vulnerable patients in the country, and the risk of suicide will always be higher with such patients, which is why measures such as the fitting of anti-ligature shower rails within psychiatric wards are put in place to keep them safe. It has been acknowledged by Mr Gray that following their investigation that immediate action was taken to replace these shower rail models within NHS Lanarkshire. Given the concerns that these particular shower curtain rails may still be in operation elsewhere in the country, I would recommend that immediate steps should be taken to replace these in every psychiatric ward.

Response

NHS Lanarkshire have removed all Goelst G-Rail 4100 Load Release System Curtain Rails (“Goelst Rails”) that were in use in our Mental Health & Learning Disability (“MHLD”) Wards. The rails have been replaced with the Kestrel Magnetic Ligature Reduction Rail System, and an annual maintenance task (including load testing) has been implemented to ensure that the rails are operating as intended. 

In order to alert the other Health Boards in NHS Scotland to the recommendation that Goelst Rails be replaced with alternative models, NHS Lanarkshire have raised an Incident Report through the National Incident Reporting and Investigation Centre (IRIC), REF INV2648 OCC4507. IRIC is Scotland’s national Incident Reporting and Investigation Centre and provides specialist safety and risk management support to Scotland’s Health Boards and Local Authorities. It manages the trending, investigation and resolution of incident reports it receives involving medical devices, IVDs, estates, facilities, social care equipment and PPE and publishes safety alerts when risks need mitigating actions at local level. Raising an Incident Report through IRIC is the most effective means available to NHS Lanarkshire to cascade this information nationally and comply with the recommendation. 

Recommendation 3

A review of the Clinical Observation and Engagement Policy and Guidelines for Best Practice’ for use by the NHS Lanarkshire Mental Health and Learning Disability Service should take place within NHS Lanarkshire. Given that all hospitals have at least the potential to deal with patients experiencing mental health difficulties, the aforementioned Policy should apply across all of the facilities and not just in a mental health setting. In the present instance there was clearly confusion as to whether the observations policy was being followed, and a review of the policy should take place to ensure that there was sufficient oversight of patients with mental health issues being treated within a medical setting. In particular the use of the Patient Observation Recording Sheet should be mandatory whenever patients are on enhanced observations, to ensure that critical information relating to events during these periods of observation are not lost.  

Response

NHS Lanarkshire Acute and Mental Health Nursing Services have initiated a joint review of observation practice across Acute and MHLDA settings. This work brings together the Acute Enhanced Observation Policy and the MHLDA Clinical Observation Policy, with the aim of ensuring greater consistency, clarity, and alignment with the Scottish Patient Safety Programme (SPSP) principles for Continuous Intervention.

Through this collaborative approach, both services are committed to improving the experience and safety of patients who present with acute mental illness or significant distress within Acute hospital environments. A key focus is shifting from passive observation to active, therapeutic, person centred intervention, ensuring that patients receive meaningful support that promotes dignity, engagement, and recovery.

This joint work will also strengthen operational clarity around resource deployment and establish clearer thresholds for when Psych-Liaison assessment is required, as this situation relates to cases where the patients physical health needs take precedence over their mental health needs and they need to be cared for in the Acute setting. In these cases, Acute colleagues will seek a psychiatric opinion on how to manage the patient’s mental health in the Acute care setting. In the context of enhanced observation, this meant allocating a member of staff to be present with the patient. Historically this did not involve interaction with the patient and could be said to lack therapeutic value. The review is already refreshing the supporting documentation to align more closely with the need to evidence therapeutic interventions. This work will include ensuring consistent patient appropriate clinical observations sheets. 

The joint review of policies will also include looking at a more therapeutic intervention based on the patient’s assessment and agreed care plan. The details of potential interventions will be agreed as part of the review.

Adherence to policy is dependent on skills and competencies, which vary across care groups. The joint review aligns Acute and MHLDA around a set of key principles, which will enhance patient safety through therapeutic intervention as opposed to passive observation.

Any enhanced level of intervention (staffing) will be supported by a Psychiatric liaison mental health and risk assessment. It will also include a recommendation around enhanced staffing, in cases where the patient is acutely distressed, or seen to be at risk of self-injurious behaviour. Colleagues within Acute will collaborate with Psychiatric Liaison colleagues as to whether this enhanced staffing should be registered or unregistered. 

These improvements directly address the learning identified through the FAI and are intended to support staff in delivering timely, safe, and compassionate care. The work on the joint review has already commenced and compliments the ongoing work of the MHLDA Continuous Intervention Implementation Group. The joint policy review will be completed by June 2026, with implementation by September 2026.

Recommendation 4

A review should be undertaken in respect of the PLNS’s role in transferring patients from acute medical ward to psychiatric wards within NHS Lanarkshire, and in relation to the role and interface of the PLNS and Liaison Psychiatry in general within acute psychiatric inpatient services. It was clear that there was significant confusion amongst PLNS nursing staff who gave evidence at the Inquiry as to the extent of their involvement when a patient was being transferred between hospitals or even between wards, particularly in relation to the difference between agreeing admission and arranging it. NHS Lanarkshire should develop and have in place a policy which should set out how and what is done in this regard and by whom, and to provide clear guidelines as to role of PLNS in the transfer process, and in relation to information being passed.

Response

The PLNs/Liaison Operational Protocol is currently under review. As part of the review, there is now an added section that outlines clear patient transfer responsibilities for Consultant psychiatry and PLNs. These amendments will be agreed and actioned via the Mental Management Team Meeting, Partnership Forum, Divisional Partnership Form and the Area Partnership Forum.  This will be implemented by the end of June 2026.

Recommendation 5

The role of the duty AMP Service within Wishaw Hospital and within NHS Lanarkshire in general should be reviewed, and consideration given to extending its current extremely limited role in relation to seeing patients and placing them on STDCs if appropriate. It was clear from the evidence of Dr Karri that he considered that the role of the AMP in NHS Lanarkshire was more restrictive than in other parts of the country, such as NHS Grampian. When assessing patients, particularly when they have not already been seen by a senior clinician or are unlikely to be seen by a senior clinician for some days, their ambit should be extended to include the development of a care plan in appropriate cases. It should not be the case that a patient presenting to a psychiatric hospital in such a disturbed condition should be waiting for three days before being seen by a senior clinician to develop their care plan.

Response

The role of the duty Approved Medical Practitioner should include devising an initial treatment plan for newly admitted inpatients, and a standard operating procedure will be drawn up by medical staff detailing the responsibilities of the AMP to include this aspect of care. This will then be submitted to the MHLD&A clinical governance group for wider discussion and approval from the group, to allow for use in daily practice.  This will be implemented by the end of August 2026.

The recommendations overall will be monitored and implementation assured by our Healthcare Governance Assurance Group.