Kerry Ann Finnigan, a 26-year-old English literature graduate, died by suicide at University Hospital Wishaw on 21 December 2019. 

Sheriff Colin Dunipace’s determination makes five recommendations: 

• Immediate replacement of all Goelst G‐Rail 4100 ‘anti-ligature’ shower rails currently in operation within NHS Scotland; 
• All patients admitted to a psychiatric ward in NHS Lanarkshire should be reviewed by a senior clinician within 24 hours of admission; 
• A review of NHS Lanarkshire policy should take place to ensure sufficient oversight of patients with mental health issues being treated within a medical setting; 
• A review of policy and guidance set out by NHS Lanarkshire to clearly define the role of the Psychiatric Liaison Nursing Service (PLNS) in transfers between wards or hospitals; 
• A review by NHS Lanarkshire of the duty Approved Medical Practitioner (AMP) role with consideration given to expanding the role so AMPs can develop care plans where appropriate and particularly for patients who may otherwise wait days to be seen by a senior clinician. 

Procurator fiscal Andy Shanks, said: “The sheriff’s determination makes detailed recommendations for both NHS Scotland and NHS Lanarkshire in how they care for psychiatric inpatients. 

“The discretionary FAI followed a thorough and comprehensive investigation by the Procurator Fiscal who ensured that the full facts and circumstances of Kerry’s death were presented in evidence.  

“My thoughts are with Kerry’s loved ones at this time.”