The HSE has admitted that a mental health unit where a man took his own life while a voluntary patient was not fit for purpose.
The inquest into the death of 30-year-old Karl Collins, who died at St Columba's Hospital in Sligo last year, also heard an apology from the HSE to the family of Mr Collins.
The surf instructor, who was originally from Sutton in Dublin, but living in Bundoran in Donegal, presented at St Columba's on 1 April 2017 with high anxiety, insomnia and chaotic thinking.
Mr Collins was admitted and given a single room.
On the morning of 3 April, psychiatric nurse Sean Gilmartin found him sitting on the floor of his room with his back to the wall.
Mr Gilmartin said Mr Collins told him he had taken ten to 12 sleeping tablets at around 5am, had not slept for days and wanted to take his own life.
The nurse informed doctors and wrote up a report and Mr Collins met a medical team at 11am.
At 1.30pm, another nurse, Stephen Misani, went to Mr Collins' room to tell him that he had a visitor, but found him unresponsive.
He activated an alarm but efforts to resuscitate Mr Collins, including the use of a defibrillator, failed.
Three doctors gave evidence that they did not assess Mr Collins as being suicidal when he presented at the unit or following his admission.
Consultant Psychiatrist Dr Edmond O’Mahony said Mr Collins told him on the morning of his death that he did not want to end his life but he was desperate to get some sleep.
He said Mr Collins was anxious and restless but articulate and was collaborating with his treatment plan, which included medication and a possible transfer to St Patrick’s Hospital in Dublin.
Barrister for the Collins family, Keith O'Grady, said that on admission Mr Collins told staff that he had tried to take his life in 2011 and this was followed by a period in St Patrick's Hospital and St Ita's in Dublin.
He questioned a number of witnesses about the level of observation of Mr Collins from the time he had said he had taken the sleeping tablets and was told that he had not been moved to the high observation unit and observation checks on him continued to be routine.
Mr O'Grady said that the HSE had apologised to the Collins family and he said that following the tragedy remedial action had been taken in the room in which he had taken his life.
Under questioning from Mr O'Grady, Tomas Murphy, Area Director of Mental Health Nursing in Sligo/Leitrim, confirmed that following safety assessments in the unit, the HSE was under notice that wardrobes in the unit posed dangers.
Mr Murphy also confirmed that the unit itself was not fit for purpose.
He said that work on a new mental health unit on the grounds of Sligo University Hospital is due to begin next month.
The jury recommended new protocols in patient observation to prevent similar deaths.
It also recommended that when a person had made a previous suicide attempt and showed clear signs of suicide ideation then they needed to be supported and a suicide observation system should be put in place immediately.
Following the verdict of suicide today, Mr Collins’ sister Maria said it was shocking to the family that Karl had sought help in what should have been the safest place, but he was able to take his life within the very walls of a HSE mental health hospital just over 50 hours after being admitted.
Ms Collins said it was vital that there was total accountability in our mental health system and that all the appropriate lessons were learned when things go wrong.
