UHG failed to tell family suicidal dad was missing

The family of a man with suicidal ideation, who went AWOL from the psychiatric unit of UHG last year, claimed that his life could have been saved had they been notified about his absence.

Coroner for West Galway, Dr Ciaran MacLoughlin, said that it was a serious omission on the part of staff that the man’s next-of-kin was not told that he had gone missing – as was the protocol – until he had died, the following day.

“I thought my brother was in good care – I could have come to Galway, even though I had my own problems (at home at the time), we would have made it our business to be here,” his sister told the inquiry.

The father of two (53), who had a history of psychiatric problems and alcohol abuse, admitted himself into the 35-bed unit at UHG on May 7 last year – a week before his death. On admission, he had expressed the desire to end his life, but consultant psychiatrist, Professor Colm McDonnell, said that he seemed to be successfully engaging with the ‘care plan’, and was due to be discharged a few days later.

As a voluntary patient, he added, he could not have been prevented from leaving if he had wanted to go.

His family, however, wanted to know why at 12.45pm on the same day he left, May 13, a case worker from the Simon Community had been required to accompany him when he requested to attend a coffee shop outside the hospital grounds – but hours later he was able to leave alone.

Professor McDonnell said that although it was a closed unit, it was not a locked one, and he may have left without informing anyone. Furthermore, he said that he was not a person who would have been detainable under the Mental Health Act, as he had come seeking help.

“It is common for people to slip out,” he said.

“Accompaniment wasn’t medically prescribed… when someone co-operates it wouldn’t be a reason to introduce extra caution. On that day, or the previous day, if he’d asked could he go out, I’d have said ‘fine’. The plan was to transfer his care to community services later in the week.

“If he’d indicated that he was going to end his life, he could have been restricted from leaving under Section 23 (Mental Health Act).”

A note taken by nurses at 4pm on the day he left stated that he was “mixing well” with other patients.

But his family claimed that he had expressed suicidal intent on the day of his disappearance, and that staff were aware of this because they had contacted his sister.

She told the inquiry that she received a call to say that her brother was not in good health. She was asked to come and care for him, but she was unable due to a family crisis with her daughter in Dublin.

She spoke to him after he came back from tea with the Simon Community worker, and he was very down. She rang him later that day, but got no answer. She continued to try to reach him into the evening, without success, as his phone was turned off.

She later learned that he had left the unit alone at 5pm, but had not been not noted as missing until 8pm. The protocol was that family members be informed straight away, but it was not until a full 24-hours later – at 5pm the following day – that Gardaí came to his sister’s home in Dublin to say that he had died.

Professor McDonnell accepted that the “standard AWOL procedure” had failed in this case.

The man was discovered hanging inside the door of his home on the afternoon of May 14. He had left a hand-written note to say that he wasn’t able to cope.

Dr MacLoughlin said that the post mortem examination indicated that the anti-depression medication that he had consumed had been absorbed into his system, so he was alive for some time after that before he took his own life.

He made a number of recommendations.

Firstly, that when a person takes their own life, having discharged themselves from hospital, there should be a review of the procedures, to which the family are invited to participate.

Secondly, in cases where a patient has presented with suicidal idealisation, they should not be allowed to leave without the consent of medical personnel.

“While they cannot be prevented from leaving, permission should be sought,” he said.

“It is not that there is a shortage of staff – there should be enough staff to know where they are, and what time they are expected back.

“There was also an omission that the family were not notified of his absence until he was found dead – that is something that should be corrected in the future.”

He sympathised with the dead man’s family, pointing out the “alarming” statistic that suicide kills more people than road traffic accidents.

“Anything we can do to help people in that space, where they feel life is so hopeless for them that they have to take their own life. It is devastating for those left behind, and is a national problem.

“We will try to make recommendations to the authorities so that, in some way, this can be reduced… My heart goes out to you for the loss you have suffered.”