A 28-year-old man who took his own life while an involuntary patient in St Columba’s mental health unit in Sligo had, five weeks earlier, told staff he wanted to kill himself or kill others, a coroner’s court has heard.
An inquest into the death of Philip Lyons from Kevinsfort, Sligo, heard that in the weeks before he died on May 3rd, 2018, the young man had tested positive for cocaine in St Columba’s.
Coroner Eamon MacGowan was told that Mr Lyons, who had been diagnosed with paranoid schizophrenia, had taken his life 25 minutes after being allowed access to a meeting room, when he asked for privacy to make a phone call to his father.
Returning a verdict of death by medical misadventure, the jury recommended that “high risk” patients should not be left unsupervised and said there should be appropriate staffing levels. The jury also urged that staff continue with ongoing efforts to halt access to unprescribed drugs.
Welcoming the verdict, Philip Lyons snr, father of the deceased, said it was important that lessons be learned.
“The jury said it all today,” he added. “A young man should not be left alone in a room for 25 minutes.” He added that the same thing had happened in St Columba’s 13 month earlier.
“They did not learn from that but now there is a new facility so hopefully it won’t happen again,” he added.
In April 2017 Karl Collins (30) a native of Sutton, Co Dublin, died by suicide in St Columba’s. The mental-health unit building, which was described as “not fit for purpose” by director of nursing Thomas Murphy in his evidence to Monday’s inquest, has closed and has been replaced by a new, €14 million facility at Sligo University Hospital.
One of the nurses on duty the night Mr Lyons died recalled that he had been watching a film earlier that evening and had seemed engaged and was laughing. There was “no cause for concern”, he told the jury.
Open hospital
Mr Murphy confirmed to counsel Keith O’Grady, representing Philip Lyons snr, that the 28 year old had tested positive for cocaine in the weeks prior to his death.
Mr Murphy said it was important to point out that St Columba’s was an open hospital with visitors free to attend. He said the Health Service Executive worked closely with the Garda in trying to address this issue.
Mr O’Grady questioned why staff in St Columba’s were surprised and shocked by Mr Lyons’s death given that he had been diagnosed with paranoid schizophrenia by psychiatrists in St Patrick’s Hospital and in the Central Mental Hospital and also given that he had threatened to either kill himself or others and that he had made two suicide attempts in the past.
The inquest also heard that the deceased had appeared before the local district court, where the sitting judge had remarked: “This is a tragedy waiting to happen.”
A multidisciplinary team meeting in the hospital on the day before Mr Lyons died concluded that he was not at high risk, the coroner was told. Consultant psychiatrist Dr Owen Mulligan, who had treated Mr Lyons from 2015 until the time of his death, said he had suffered from paranoid schizophrenia and had comorbidities including polysubstance abuse, Asperger’s syndrome and dissocial personality disorder.
Mr Lyons was first referred to the mental-health services at the age of 19. His psychosis was characterised by a wide range of symptoms such as persecutory delusions, unusual beliefs that he had travelled back in time and that his family was really dead, and delusions that he was the son of God. His judgment was impaired and he used substances including cannabis, cocaine, MDMA (ecstasy) and alcohol.
In July 2017 he had seriously assaulted another patient and was arrested and remanded to Cloverhill prison. On release he was admitted as an involuntary patient to St Columba’s. After being switched to a new drug early in 2018 there was a noticeable improvement in his mental state and he was able to avail of short periods of escorted leave from the hospital accompanied by nursing staff, Dr Mulligan said.
Speaking after the jury delivered its verdict, Mr Lyons said it was important not to forget that a young man with “hopes and dreams like any young man” had lost his life.
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