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AN inquest into the death of a patient who took his own life while under the care of the Western Health Trust’s mental health services in Omagh has found that his death was preventable.
Rory Patrick Hughes died on December 15, 2019, after leaving the Lime Ward at the Tyrone and Fermanagh Hospital unaccompanied and travelled to Derry, where he jumped from the Foyle Bridge.
Mr Hughes was an in-patient at the time, and the inquest heard a series of failings in the care provided to him, including concerns around unaccompanied leave, risk assessment, record-keeping and communication with his family.
Delivering her findings today, Coroner Maria Dougan concluded that Mr Hughes’ death could have been prevented had the decision to allow unaccompanied leave been properly reviewed, and had an Absent Without Leave policy been activated promptly when he failed to return to the ward.
The Coroner said that following Mr Hughes’ re-admission to the Lime Ward in June 2019, after a discharge the previous month, a comprehensive safety plan should have been put in place.
“This was a missed opportunity to enhance protective measures,” the Coroner said. “A safety plan could have helped Rory in dealing with suicidal thoughts.
“It is accepted by the Trust that a risk assessment ought to have been maintained and regularly reviewed throughout the entirety of his admission to the Lime Ward.”
The Coroner also criticised the quality of clinical records on the Trust’s PARIS system, describing them as lacking in detail and highlighting the absence of a clear management plan.
“I find, acknowledged by psychiatrist Dr Patrick Manley, that clinical notes were inadequate,” she said. “Existing on the Lime Ward is a systematic culture of poor note-keeping, representing a broader service failing.”
The inquest also heard that, in the weeks before Mr Hughes’ death, his family had provided what were described as important and relevant emails outlining concerns about his wellbeing.
“There was no evidence that this input was acted upon,” the Coroner said. “These detailed and insightful emails from family members ought to have been acknowledged.”
It was further found that Mr Hughes’ unaccompanied leave on the day of his death had been authorised by someone who did not have the statutory authority to do so.
The leave was granted by a psychiatrist who had briefly overseen Mr Hughes’ care in the days before his death.
Overall, the Coroner said a lack of awareness among staff on the Lime Ward was a matter of concern.
In her formal conclusion, the Coroner stated that Mr Hughes ‘died as a result of his own act when his mind was disturbed as a consequence of his diagnosis of schizoaffective disorder’.
A post-mortem confirmed the cause of death as multiple injuries and drowning.
Concluding the inquest, the Coroner described Mr Hughes as a ‘much-loved son and brother’.
“These findings highlight the need for further suicide prevention training,” she said. “They also underline the significant contribution family members can make to a patient’s care.”
In response, a spokesperson for the Western Health and Social Care Trust said, “We would like to express our condolences to the family of Mr Rory Hughes. We will carefully consider the Coroner’s findings and take forward any learning identified.”
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