Michael Dodds, diagnosed with post-traumatic
stress disorder, took his own life at NHS Tayside's Carseview Intensive
Psychiatric Care Unit in Dundee.
An inquiry into his death heard
that trainee GPs with no psychiatric experience were left to care
for vulnerable patients.
It also emerged that the hospital
kept no record of whether patients had items they could use to harm
Mr Dodds, 38, of Dundee, hanged
himself on September 8, 2007.
During the fatal accident inquiry
at Dundee Sheriff Court, Dr Helen Millar, a consultant psychiatrist
at Carseview for 10 years, criticised a system that put GP trainees
with no psychiatric experience on a three-month rotation there.
Dr Millar wrote to the medical director
urging that the system be changed. This eventually happened but
only after Mr Dodd's death.
In a written ruling, Sheriff Derek
Pyle said: "The failures in this case were obvious.
"The system for a written record
of possessions was totally ignored.
"The movement of such possessions
was not recorded in writing in the nursing notes, resulting in there
being no record that Mr Dodds was already in possession of a trouser
The sheriff said staff nurse Stephen
Duncan failed to take "even the most basic steps" before
he gave Dodds the belt that claimed his life.
He added: "The decision to
give Mr Dodds the holdall strap was taken by one nurse without consultation
with his colleagues, in particular a doctor.
"Having given the strap to
Mr Dodds he (Stephen Duncan) failed to watch closely what Mr Dodds
wanted to do with it, and he failed to record the event in the nursing
Sheriff Pyle also found that nursing
staff lacked refresher training and they there was insufficient
supervision from superiors.
The Dodds family solicitor, Brian
Bell, said: "This is one of the most shocking cases of neglect
we have encountered."