THE inquest into the death of 28 year old Philip Lyons heard that the day before he died, the involuntary inpatient at St Columba’s Hospital had gone AWOL and, in the days before he took his own life, he was sullen and staying in bed.
His Consultant Psychiatrist Dr Owen Mulligan told the inquest Mr Lyons’ care needs were complex and although he showed signs of deterioration in January 2018, there was a noticeable improvement week on week prior to his death.
Barrister Mr Keith O’Grady BL for Mr Philip Lyons Snr said that five weeks before he died, he told staff that he was going to kill himself or somebody else. Dr Mulligan said that when Mr Lyons requested medication but was refused, he tended to become frustrated and angry but this would subside.
Mr Lyons was allowed access to a meeting room where he was left unsupervised for 25 minutes after he asked for privacy to make a phone call to his father. He was later found unresponsive by staff and was pronounced dead at 11:05pm on May 3rd 2018.
When asked by Mr O’Grady if he thought it was appropriate Mr Lyons was allowed into a room on his own for 25 minutes, the psychiatrist replied the indicators of self harm were not there as Mr Lyons didn’t appear emotionally distressed and was speaking to his father about money.
Mr O’Grady said on March 26th 2018, he had been verbally aggressive with staff and was telling them he was going to do it. He said that on April 29th 2018, four days before he died, the note is that Mr Lyons had stated he had feelings of depression and on the same day he spent most of the day in bed. He appeared drowsy and incoherent. On April 30th 2018, three days before his death, he wouldn’t get up for breakfast and was described as being sullen in mood and was having little interaction with the people on the ward.
In the early hours of May 1st 2018, he was lying on the floor and refused to go to bed and was pacing the corridors.
Mr O’Grady asked the doctor if he knew about this and he replied it was not out of character for him if he was asking for medication.
The barrister said Mr Lyons was agitated two days before his death and that on May 1st he admitted taking xanax which was brought into the hospital by another patient.
Mr O’Grady said the day before he died, he went missing and the note described him as ‘AWOL’.
He said this a man that was supposedly improving and said surely he must not stand over the assertion that this death came a surprise. The doctor said the overall direction of his improvement was positive and he had complex needs and was sourcing drugs from other people. He said there were good indicators in that while he absconded for a few minutes, he did come back.
The barrister referred to July 2015 when a doctor from the Central Mental Hospital, giving evidence in Sligo District Court, said that Mr Lyons’ case was a ‘recipe for disaster’ as his treating consultant at the time did not accept his diagnosis and thought he had a personality disorder. He said it made local and national news with Judge Kilrane saying the behaviour of St Columba’s Hospital was difficult to explain and they were quite possibly dealing with a tragedy with this young man.
Mr O’Grady asked Dr Mulligan did he accept in anyway that Mr Lyons’ death could have been prevented and he said he didn’t think it could have been predicted.
Dr Mulligan told Ms Lorraine Scully BL with Mr Bryan Armstrong (solicitor) for the HSE that Mr Lyons would attend some of his multi-disciplinary meetings, which included social workers, nursing staff, occupational therapists and consultants. He said that Mr Lyons would go sometimes to the meetings. He said he very much enjoyed occupational therapy and in particular the horticultural project in the hospital which included a pet goat which he was fond of which was nice to see. He said that the hope was down the line that Mr Lyons would live in some supported accommodation and there was a long road to him living on his own but that was the aim of his treatment plan.
He said it certainly was the best he had seen him since being involved in his care.
He never believed he had a mental illness and preferred taking recreational drugs although there was a lot of effort put in including addiction counselling to try and address this. He also had restricted mobile phone access. He said he had a plan in place with his father about money which he followed. He said Mr Lyons Snr had always been an unconditional support to him and always available to him. The doctor expressed his sincere condolences to all of Mr Lyons’ family in court.
The jury asked the nursing staff about the staff ratio on the night and were told it was three nurses to 18 patients.
On addressing the jury, Coroner Eamon MacGowan said this was a case of a young man who was suffering with mental anguish for a long number of years, it was not an unlawful killing or a death of natural causes. He said they could reach two verdicts, death by suicide or medical misadventure. He asked them to reach a unanimous verdict .
After deliberating, the jury of 5 men and one woman reached a verdict of death by medical misadventure. They said they believed it was a failure of the hospital system and that a high risk patient should not be left unsupervised and there has to be appropriate staff levels. Another recommendation was that staff should continue their efforts to halt access to unprescribed drugs.
Mr MacGowan said to the Lyons family that nothing would bring Philip back and he expressed his sympathies on their great loss.
Mr O’Grady said on behalf of the Lyons family, they wanted to thank the coroner, the jury and members of An Garda Síochána who liaised with the Lyons family which was very much appreciated by Mr Lyons Snr.
Sergeant Derek Butler on behalf of An Garda Siochána expressed his sincere condolences.
Counsel for the HSE, Ms Scully also expressed condolences, as did the jury.