The jury at the inquest into the death of a 28-year-old man in a mental health facility in Sligo has found that his death was due to medical misadventure and made several recommendations relating to the supervision of high-risk patients and access to unprescribed drugs.
The inquest into the death of Philip Lyons of Kestrel Drive, Kevinsfort in Sligo heard from a senior staff member at the facility that access to illicit drugs by clients was, and still is, an issue.
Philip Lyons had been an involuntary patient in St Columba's mental health hospital for over a year when he died there on 3 May 2018. The facility, which was described as "not being fit for purpose" at Sligo Coroner's Court today, has since closed and been relocated to Sligo University Hospital.
The inquest into Mr Lyons death heard that he suffered from paranoid schizophrenia, Asperger's Syndrome, and Dis-social Personality Disorder which was complicated by polysubstance misuse including cannabis, cocaine, ecstasy, and alcohol.
He first came into contact with the mental health services at the age of 19 and had numerous admissions to St Columba's Hospital as well as to St Patrick's Hospital and the Central Mental Hospital in Dublin.
On the night that he died Mr Lyons had asked a psychiatric nurse for privacy to make a phone call to his father and was given a phone and allowed into a room on his own. Approximately 25 minutes later, when another nurse required the handset, Mr Lyons was found in the room and attempts were made to revive him before he was taken to Sligo University Hospital where he was pronounced dead.
Evidence was heard from psychiatric nurses who said they had no cause for concern for Mr Lyons on the evening he died. One said his death came as a complete surprise to him.
Consultant Psychiatrist Dr Owen Mulligan said that Mr Lyons had complex care needs but never believed he had a mental illness. He said there was clear evidence of things improving up until the time of his death.
Asked by barrister for Mr Lyons family, if he thought his death could have been prevented, Dr Mulligan said he did not think his death could have been predicted. Dr Mulligan said he did not present as an underlying suicide threat.
Keith O'Grady, barrister for Philip Lyons Senior, detailed medical notes related to Mr Lyons prior to his death including two attempts to take his own life and two other incidents of self-harm and referred to an occasion when Mr Lyons was before Sligo District Court and then Judge Kevin Kilrane stated that he felt "this was a tragedy waiting to happen".
Reading from his medical notes, on 26 March, Mr O'Grady said that Mr Lyons had become physically and verbally aggressive and said that he would kill someone or kill himself.
On 19 April Mr Lyons tested positive for cocaine. On 29 April, four days before he died, it was recorded that he had feelings of depression and spent most of the day in bed. On 30 April it was noted that he would not get up for breakfast and was sullen in mood and in May he took xanax which had been brought in by a fellow patient.
Mr O'Grady said that the autopsy following his death found a small amount of cocaine in his system.
Dr Mulligan agreed that Philip Lyons had gone AWOL on the day before he died and said that technically he had broken the conditions of his short outings on the grounds, but, he said, he came back within minutes, and Dr Mulligan saw more positive in this than negative and said he believed that Mr Lyons was getting benefit from his care plan.
Tomás Murphy, Area Director of Nursing at the time of Mr Lyons death, said that when he was in their care there was a period of time when they tried to transfer Philip Lyons to the Central Mental Hospital, but capacity was an issue then.
In relation to his testing positive for cocaine in the weeks before he died, Mr Murphy said it is an open hospital and visitors are free to come in and there was an issue with people throwing drugs into a courtyard of the building.
Mr Murphy said they implemented a search policy and random testing but could not search visitors. He said it is likely that a visitor brought the cocaine into the hospital, and he said access to illicit drugs is still an issue.
He said that as Covid visiting restrictions are lifted it will be a challenge going forward and always will be.
Mr Murphy confirmed that a risk assessment had been carried out by the multi-disciplinary team the day before his death and there were no indicators of him being a risk to himself at the time. Neither was there any indication of risk moments before his death, he said.
In relation to risk assessments of the building in which Mr Lyons had died, Mr Murphy said they were dealing with a building which was not fit for purpose.
He said that an external company had come from England to carry out an assessment of risk points but had not noted an issue with the room where Mr Lyons had taken his life and another assessment following his death also missed the issue.
Sligo County Coroner Eamon MacGowan told the jury members that there were two verdicts they could consider, suicide or, in light of what they had heard, medical misadventure.
The jury said they believed that the death of Mr Lyons was due to the failure of the hospital system and recommended that high risk patients should not be left unsupervised and that there should be appropriate staff levels.
The jury also recommended that the authorities should continue efforts to halt access to unprescribed drugs for patients.
Following the inquest into his son's death, Philip Lyons Senior asked, that amid all the evidence that come out, people not forget that a young man had lost his life.
"My eldest son, he had hopes and dreams, he wanted to go to university, have a girlfriend, have a life and before he could do that he died, and he died in a mental health facility where I thought he would be safe."
Mr Lyons said that his son had died alone in a room and his mind must have been in a very, very dark place.
"A valuable life was lost", he said, "there is so much he could have given to the world, but he's gone now, and I just hope lessons are learned and a tragedy like this will never happen again."
