Coroner questions quality of psychiatric care

A young man who died by suicide when he set alight a car in which he was the sole occupant could have suffered as a result of “revolving door” mental health services, an inquest into his death was told.

The 31-year-old man died when his car was engulfed by flames at Corrib Park on New Year’s Eve, 2017.

In his deposition to the inquiry, the man’s father told Coroner, Dr Ciarán MacLoughlin, that both he and his wife believed their son had left to go to his girlfriend’s house.

Sub-station officer at Galway Fire and Rescue, Ciarán Oliver, told the inquiry that fire services had been called to the scene at 11.27pm on the night in question and while it was not immediately apparent, they soon became aware that there was somebody in the vehicle.

“It was apparent from the nature of the fire that there was no sign of life in the person in the car,” he stated.

Dr Dennis Higgins confirmed the death at 9.40am on the morning of January 1, 2018. The deceased had to be identified using dental records.

Consultant Psychiatrist at UHG, Dr Brian Hallahan, told the inquest that the deceased had first been referred to the hospital’s Mental Health Services in 2008 but despite numerous appointments and several re-referrals, his engagement with the service had been minimal.

Dr Hallahan said it was “per usual practice” that if appointments were missed and a patient disengaged with the services, they would be discharged from the service, adding that they could always be re-referred by their GP.

“[The deceased’s] last engagement with Galway Mental Health Services was in 2014,” said Dr Hallahan.

The Coroner, Dr MacLoughlin, expressed alarm that this would be considered “usual practice”.

“It would appear to me that the deceased was unwell for a long time and part of his unwellness was his inability to continue contact with the services.

“It’s just letter after letter after letter. It’s a revolving door with no humane result,” said Dr MacLoughlin.

“To end his life in such a violent manner is distressing to everyone,” the Coroner said.

Dr MacLoughlin pointed out that an effective psychiatric community nursing system could combat this, given that some psychiatric patients are not unwilling, but rather unable to make contact with the services.

“A lot of psychiatric patients are not in a position to make a decision in their own best interests and the ramifications of that decision may not hit them.

“Why don’t you have a community psychiatric nurse to let them know that there is a caring, responsible and informative service there,” said Dr MacLoughlin.

Dr Hallahan said there was a mechanism in place for home visits and that many patients were in touch with an occupational therapist.

He disputed that the service was not caring, responsible and informative.

Dr MacLoughlin said that the inquest was unfortunately the only opportunity for the effectiveness of these mechanisms to be publicly examined.

“The only opportunity any public inquiry can look at these services is when someone dies.

“Had [the deceased] been attended to, or maybe seen by a community psychiatric nurse, he may still have refused to go, but we don’t know,” he said.

Deputy State Pathologist, Dr Linda Mulligan, carried out a post mortem examination on the deceased on January 2.

“There was extensive fire damage over the majority of the body. Histology confirmed the presence of soot in the airways,” said Dr Mulligan.

Dr Mulligan said there was no indication from the post mortem of the involvement of another party.

Dr MacLoughlin extended his sincere sympathies to the family and friends of the deceased.

“The cause of death was the inhalation of toxic gasses as a result of a fire,” said Dr MacLoughlin in passing verdict.