Philip, a 28-year-old Sligo man was an involuntary patient in St Columba’s Hospital at the time of his death in May 2018, Emma Gallagher reports
The father of a young man who took his own life while being an involuntary patient in the since closed St Columba’s Hospital said after his inquest he hoped lessons have been learned.
A verdict of death by medical misadventure was returned by the jury at Philip Lyons’ inquest before Coroner Eamon MacGowan at Sligo Courthouse on Monday.
They made several recommendations including that high risk patients should not be left unsupervised, that appropriate staffing levels should be in place and that authorities’ efforts to halt patients’ access to unprescribed drugs should continue.
The inquest heard extensive evidence leading up to the events of May 3 2018 when Mr Lyons was found unresponsive by hospital staff in a meeting room.
He had first been involved with the mental health services when he was 19 and had multiple admissions, including to St Patrick’s Hospital and the Central Mental Hospital in Dublin.
He had made two previous attempts to take his life and had self-harmed.
The inquest heard that five weeks before his death he had told hospital staff he was going to kill himself or others.
The day before he died, a meeting took place with his treating multi-disciplinary team which found no indicators that he was of risk to himself.
The inquest heard he also tested positive for cocaine in the weeks prior to his death and had also been taking xanax which had been given to him by a fellow patient.
Mr Lyons suffered from severe mental illness, namely Paranoid Schizophrenia and also had comorbidities including Polysubstance Abuse, Asperger’s Syndrome and Dis-social Personality Disorder.
His illness was complicated by polysubstance misuse including cannabis, cocaine, ecstasy, and alcohol.
The Director of Nursing at the hospital at the time of Mr Lyons’ death Tomás Murphy told the inquest that there was a problem with patients’ accessing illicit drugs and efforts were being done to work alongside the gardaí to combat this but searches could not be carried out on hospital visitors.
He said it was an open hospital and there were suspicions that drugs were being left into a courtyard by people.
Searches of bedrooms and testing of patients were being carried out, but hospital visitors could not be searched, he said.
At the time of his death, Mr Lyons was receiving treatment as an involuntary patient under the provisions of the Mental Health Act.
On May 2nd 2018, the day before Mr Lyons’ death, a meeting of his multi-disciplinary team found no indicators of risk to self at that time.
On the night he died, at 9:55pm, he had asked a psychiatric nurse for privacy to make a phone call to his father and he was allowed access to a meeting room, where he had been unsupervised for 25 minutes, the inquest heard.
He was found by hospital staff unresponsive and efforts were made by staff to resuscitate him and he was transferred to Sligo University Hospital by the emergency services, where he was pronounced dead at 11:05pm.
His father, Philip Lyons Snr, said after the verdict was returned that his son’s death should not be in vain and he hopes lessons have been learned and this doesn’t happen again.
“Don’t forget that a young man lost his life, my eldest son.
“He had hopes and dreams like any young man.
“He wanted to go to university, he wanted to have a girlfriend, he wanted to have a life, and before he could have that he died.
“He died in a mental health facility, you know, where I thought he’d be safe, and I trusted he’d be safe, and he died alone in a room,” he said.
“His mind must have been in a very very dark place.”
He said he will be haunted by the fact his son could still be alive today.
“Maybe he could have had a life and that’s something I will always ask myself, you know, I have to live with that
“A valuable life was lost, so much he could have given to Ireland, to the world, and he’s gone now.
“I just hope the lessons are learned and that such a tragedy will never be repeated again,” Mr Lyons said.
The old St Columba’s Mental Health facility, which was over 100 years old, was described as being ‘not fit for purpose’ the inquest heard and has since relocated to a new €14m facility at Sligo University Hospital. Mr Murphy said the transfer had taken place in November 2020 and €14m had been invested into the new facility.
Mr Lyons’ death came as a shock to the psychiatric nurses who had been working with him, the inquest heard, and they had no cause for concern.
Dr Owen Mulligan, who was Mr Lyons’ Treating Consultant from 2015 until his death, said he had complex care needs but Mr Lyons never believed he had a mental illness.
In January 2018 his mental state had deteriorated and his medication was changed and he continued to receive treatment in a High Observation Area until February 16th. He said there was a noticeable improvement in his mental state and although he still presented with marked residual symptoms of his illness, these were less frequent.
Mr Lyons was able to avail of short periods of escorted leave along with nursing staff, including going for walks. In April 2018, it was discussed and agreed with him to gradually increase his liberty from the ward, reflecting some of the recovery in his mental state.
Although there were still incidents, such as the positive cocaine test on April 19th 2018, it was felt as part of Mr Lyon’ positive therapeutic plan to have periods of 15 minutes unaccompanied leave from the ward up to three times a day, which was in place at the time of his death.
Tomás Murphy, Director of Nursing at the time of Mr Lyons’ death, said that they had tried to get him a place in the Central Mental Hospital previously but that was unsuccessful due to a lack of capacity.
Barrister Mr Keith O’Grady BL with Mr Gerard McGovern (solicitor) asked Mr Murphy how could it be that Mr Lyons had access to illegal drugs while he was a resident and tested positive for cocaine weeks before he died, Mr Murphy responded that it was very important to say that St Columba’s Hospital was not a secure environment. He said it was an open hospital at the time and people including friends and family were free to come and go. They were working with gardaí to address the issue, he said.
Mr O’Grady said that Mr Lyons had 4 previous episodes of self-harm and five weeks before he died, he had been threatening and physically abusive to staff and voiced that he was going to kill someone or himself.
He said that the hospital’s own files said he was going to do it but however a risk assessment carried out a day before he died on the 2nd of May 2018 by Mr Lyons’ multi-disciplinary team found there were no indicators of a risk to self of a man who weeks before his death had tested positive for cocaine and said he was going to kill himself.
Evidence had earlier been heard that observations of patients were carried out every 2 hours and the Director of Nursing told him that had since changed.
The inquest also heard that in March 2015 a risk assessment of the hospital had been carried out by an expert company brought over from the UK who had identified a number of potential risks but they had not picked up on a potential risk in the meeting room. It was also missed again in a risk assessment carried out six weeks after Mr Lyons died.
Mr O’Grady said that on April 3rd 2017, another young man, Karl Collins, had also taken his own life at the hospital, 13 months before Mr Lyons.
He said that in the case of Mr Collins, there was an apology but there was never an apology in this case.
A year before Mr Lyons died in 2017, he had been awaiting transfer to the Central Mental Hospital, he had appealed this but was unsuccessful. On July 27th 2017 he assaulted another patient and was remanded to Cloverhill Prison where his admission under the Mental Health Act fell away. He remained in Cloverhill until November 10th 2017 where he was readmitted to St Columba’s Hospital as an involuntary inpatient.
His treating Consultant Psychiatrist Dr Mulligan told the inquest that Mr Lyons’ did suffer from a very severe mental illness all of his adult life and probably going back to his adolescence but it was not the plan at the time of his death to get him a place in the Central Mental Hospital and he said he was very hopeful of the progress he was making.