Death of Davin Corrigan was ‘preventable’, inquest finds

THE family of Sion Mills man Davin Corrigan who died while he was a patient at a mental health unit situated at Gransha Park, Derry has welcomed the findings of an inquest which found his death was ‘preventable’.

In a statement outside Laganside Courts in Belfast, the Corrigan family thanked the coroner, and said that the inquest had reiterated ‘something they always knew’.

The family said, “We welcome the findings of the Coroner today who found Davin’s death was preventable, something we have always known. The Coroner has found that there were numerous failings by the Western Trust, RQIA and NIAC.

“One of the most shocking findings is that changes should have been made as far back as 2015, three years before Davin’s death.

“We acknowledge that the Western Trust and RQIA have accepted the failings and are working to put things right to ensure this never happens again.

“Davin’s memory will live on in the Davin Corrigan Legacy award. Davin is our hero but far more importantly, he is the legend that he always strived to be.”

Davin Corrigan, 25, died by suicide at the Grangewood unit in November 2018. He was described as being extremely popular and had an “infectious personality” and would “light up a room”.

The Inquest held this afternoon found that multiple agencies including RQIA and the Western Trust could have done more to prevent the his death.

The coroner found that the system that staff had to report serious incidents at the mental health facility was not fit for purpose and staff did not know how to use it correctly. There had been a number of suicides and attempted suicides in similar circumstances on Carrick ward – where Mr Corrigan died – which dated back to 2013.

The coroner also found that RQIA did not hold the Trust to sufficient account surrounding patient safety. The Coroner also said that even though the government watchdog had suggested improvements from as early as 2015  there was not enough guidance or a timeline set in place for these to be implemented.

The court also heard that RQIA failed to inspect the Grangewood unit after Mr Corrigan died, despite a complaint from his mother.

A spokesperson for the Western Trust said, “The Western Trust and everyone involved in Davin’s care would like to reiterate its sincerest condolences to the Corrigan family for the death of Davin.

“The Trust wholeheartedly accepts the failings regarding the care of Davin. The Trust’s investigation following Davin’s untimely death concluded that his death in that way and at that time was preventable.

“Remedial action has been taken and further risk management procedures have been put in place since Davin’s death to help prevent further reoccurrences of such incidents.

“The Trust in partnership with the family has established a Davin Corrigan Legacy Award promoting collaboration with service users and carers in service improvement.  We are firmly focused on developing and embedding patient and service user safety into our services going forward through engaging with patients, service users, and their families.”