The son of singer Sinéad O'Connor absconded from Tallaght University Hospital while he was meant to be under 24/7 supervised care as a high-risk patient less than 24 hours before his body was discovered in a secluded area just outside Bray, Co Wicklow.
An inquest into the death of 17-year-old Shane O'Connor heard the teenager had gone missing on the morning of 6 January 2022 from the hospital where he was being treated for a drug overdose.
His body was found by a workman the following morning on the edge of wasteland at the rear of the Corke Abbey housing estate in Bray.
A sitting of Dublin District Coroner's Court heard that there was no healthcare assistant available at TUH to provide Shane with the required continuous supervised care on the morning he left the hospital shortly after he had been stopped by a nurse when trying to go outside for a cigarette.
The inquest heard that Shane's mother Sinéad, who died suddenly 18 months later in London, had formally identified her son's body to gardaí at the mortuary in St Colmcille's Hospital in Loughlinstown on 8 January 2022.
The coroner's court also heard she had brought her son to TUH's emergency department when he was admitted to the hospital on 29 December 2021.
Among those attending the hearing were Shane's father, musician Dónal Lunny, his grandfather Seán O’Connor and his uncle, Sinéad’s brother and novelist, Joseph O'Connor.
Others in attendance included Shane's half-brother, Yeshua Bonadio, as well as Sinéad’s former husband, John Reynolds.
Prior to his admission, Shane had been under the care of Tusla and had been residing at a care facility operated by New Beginnings in Newbridge, Co Kildare, after living with his mother until the age of 11.
A consultant gastroenterologist who was responsible for Shane's treatment at TUH, Anthony O'Connor, apologised for what happened to Shane under his care and said the teenager's death had greatly affected all the medical team.
Dr O'Connor expressed his "profound regret and shame" that one-to-one supervision had been unavailable to Shane due to challenges posed by Covid-19 restrictions, which had resulted in 15% of staff being out of work with the infection at the time.
"Although it was clear that he was unwell and troubled, his gentleness, kindness and creativity was apparent to all," the consultant added.
The inquest heard Shane had been admitted to TUH after a drug overdose which had resulted in severe injury to his liver.
While his condition improved dramatically after treatment, Dr O'Connor said he continued to have "deep concern" for the patient.
However, he admitted he was wrong in not thinking that Shane posed a high risk of leaving the hospital unattended because he had been "pleasant and cooperative".
A consultant liaison psychiatrist at TUH, Paula McKay, said staff had identified the need for constant supervision of Shane while he was in the hospital.
The inquest heard such supervision was being provided by a combination of hospital staff, New Beginnings carers and Mr Lunny until he tested positive for Covid-19 but it was not on a 24/7 basis including the two nights before he absconded from the hospital.
However, Dr McKay said she had not been informed about times when such supervision was not being provided which she could have escalated if she had known.
In reply to questions from the coroner, Cróna Gallagher, she said she believed Shane had met the criteria for being involuntarily detained under mental health legislation which might have arisen at a scheduled court hearing about his care on the day of his death.
The inquest heard that a new policy had been introduced in TUH following Shane's death which prioritised high-risk patients in need of 24/7 supervision which was reviewed on a daily basis.
A nurse raised the alarm that Shane was not in his room shortly after 10.30am, while security staff established from CCTV cameras that he was seen leaving the hospital around 10am.
At one stage, Joseph O'Connor said evidence that TUH had to withdraw the offer of jobs to 20 additional healthcare staff because the HSE had withdrawn funding for recruitment was "pretty shocking".
"It’s an absolute incredible state of affairs," Mr O'Connor remarked.
Shane's grandfather objected to detailed evidence being given from a witness about his grandson’s history of care.
Seán O'Connor said it was known that Shane had a difficult youth and questioned the need to go back further than his admission to TUH.
He said his daughter had often spoken to him about her son, but he did not believe the inquest should "rake over dead embers" and just wanted it to focus on the "system that allowed Shane to escape from hospital".
"I’d prefer if that is where we began and ended," he added.
He said Shane’s family accepted that all healthcare staff had tried to do their best for him.
He told the coroner that he wished to know why there was no protocol in place at the time and why a mentally ill child was not transferred to a psychiatric ward.
Mr O'Connor stressed that his family were not trying to cover up anything personal.
The coroner ruled that she had no wish to intrude on anyone’s personal life but some evidence needed to be heard about the treatment received by the deceased.
Dr Mary Rose McCarthy, a consultant psychiatrist at South Kildare Child and Adolescent Mental Health Services, subsequently gave detailed evidence about diagnosing Shane with a mental and behavioural disorder, which she linked to his regular misuse of cannabis.
Dr McCarthy outlined how the troubled teenager, who was assessed with an IQ in the gifted range, was admitted to the Linn Dara in-patient psychiatric unit at Cherry Orchard Hospital in Ballyfermot, Dublin, on six occasions between February 2020 and December 2021 for a total of 127 days, including one stay which lasted 42 days.
The inquest heard that his mother had said there were long-term difficulties in getting her son to engage with any support services.
Dr McCarthy said Ms O'Connor had contacted her in August 2021 about how her son's condition was "highly challenging".
The witness said Ms O'Connor had spoken of how she loved her son but was overwhelmed by the situation and unable to provide support to him at that time.
Dr McCarthy said she believed Shane could have improved if he stopped taking cannabis but he was unwilling to give the drug up.
She also noted it was difficult to support him safely "in a residential setting".
The psychiatrist became tearful as she expressed how "extremely sorry" she was that the teenager did not get a chance "to live out a long life and realise his thoughts and dreams".
She said arrangements were being made for him to be admitted again to Linn Dara at the time of his death.
Garda Seán Savage gave evidence of being informed that a body was discovered at around 9.15am on 7 January 2022 by a contract worker, Jonathan O’Toole, who said he had seen nothing at the same location when he left work the previous day.
The inquest heard the last sighting of Shane was when he was captured on CCTV buying an item in the Woodie's DIY store in Bray, Co Wicklow, at 3.24pm on 6 January 2022.
Garda Savage said there were also CCTV images of Shane taking a bus to Bray but he had been unable to track how he had left the Tallaght area.
In reply to questions from Dr Gallagher, he said that Shane had appeared normal on CCTV footage and was on his own at all times.
The inquest heard a receipt, a can of Coke and an unopened packet of sweets were discovered on Shane's body, when he was formally pronounced dead at 11.15am by a doctor who attended the scene.
The inquest before a jury of six men and two women is due to conclude tomorrow.
