An inquiry into the death of a patient who disappeared last year from Gorey District Hospital in Co Wexford has recommended that alarms be fitted immediately to all fire exits at the hospital.
The patient who disappeared was found dead at a building site the following day, having left the hospital through a fire exit.
The report, released to The Irish Times under the Freedom of Information Act, found that staff were aware of the patient's confused state and had ensured all doors in the hospital were locked, with the exception of fire exits.
It emerged during the inquiry that Mr John Byrne (88) had left the hospital through the same fire exit the evening before his "tragic" death, on January 29th, 2001. However, this had not been made known to all staff, or to the director of nursing or senior board management. This was a "serious weakness", the inquiry found.
"Had such occurrences been reported there would have been an opportunity for management to have taken additional safety and protection measures such as having alarms fitted to the fire exit doors," the report said.
It added that Mr Byrne was kept under close staff observation. However, while staff were "checking-in some drugs" in a treatment room, he disappeared. The inquiry concluded that it was "not unreasonable for the two nurses on duty to jointly have attended to an essential duty for a few minutes, leaving this particular patient out of their sight for the short period of minutes that were involved".
It believed the patient had been appropriately admitted to the hospital and that measures in place and being put in place to protect patients in a confused state were "to a large extent satisfactory".
However, it called for staffing levels to be reviewed. In this context, the report said: "On the one hand it certainly can be argued that had more staff been available on duty at the time there would have been a much reduced opportunity for the patient to have left as he did. However, no evidence was given to us that inadequate staffing was a factor which led to this incident."
It also recommended that the hospital consider having only one gate open after 5 p.m., that lighting in the grounds be improved, that a monitoring system be installed and that the installation of an internal camera surveillance system, which had begun before the incident, be completed.
Mr Byrne is not named in the report but his identity was revealed when he was reported missing last year.