HSE admits failings over death of man (30) by suicide in its care

Karl Collins, an outdoor activity instructor, died in Sligo mental health unit in April 2017


The family of a 30-year-old man who took his own life in St Columba’s mental health unit in Sligo said on Monday that the most troubling aspect of his death was that he had sought help from the experts “but still ended up dying alone and in terrible emotional distress”.

A jury returned a verdict of death by suicide in the case of Karl Collins, an outdoor activity instructor from Co Dublin who had been living in Tullaghan, Co Leitrim prior to his death on April 3rd 2017, two days after being admitted voluntarily to the Sligo unit.

Five hours before he was found, he told a nurse that he had taken 10 to 12 sleeping tablets as he wanted to “end it all”.

Keith O’Grady BL counsel for the Collins family repeatedly pressed HSE witnesses on why the young man who was a qualified surf instructor and trained mountain leader, had not been put under high observation after telling staff he had taken tablets and wanted to end it all, especially given that he had been hospitalised in 2011 following a suicide attempt.

After delivering its verdict, the jury recommended health staff immediately put in place suicide observation systems in cases where there had been a previous suicide attempt and where someone was showing suicide ideation.

It also recommended there be ongoing training to help staff deal with emergency situations, and that HSE staff should encourage anyone who had made a suicide attempt or who was suicidal , to stay in touch with family.

A HSE executive agreed at Sligo Coroners Court on Monday that the unit where the young man died was “not fit for purpose”.

Karl Collins, an outdoor activity instructor from Co Dublin who had been living in Tullaghan, Co Leitrim, died on April 3rd 2017.
Karl Collins, an outdoor activity instructor from Co Dublin who had been living in Tullaghan, Co Leitrim, died on April 3rd 2017.

Area director of nursing Tomas Murphy said construction of a new unit was due to start in the grounds of Sligo University Hospital within a month.

The jury heard that an audit of ligature points carried out by the Mental Health Commission in this unit had found that there were 365 such sites within the unit. Some 118, or 32 per cent of these, were removed over a 12 week period.

Mr Collins, who was described by staff as “a pleasant young man”, was voluntarily admitted to St Columba’s, the inquest heard. Two days later, a nurse went to his room at 1.30pm to tell him that his girlfriend was there to visit him. He found the patient unresponsive.

Speaking after the verdict, Mr Collins’s sister Maria said the family felt terribly let down. Their brother had in his time of greatest need, sought help in the most obvious place, a HSE mental hospital and “just 50 hours later he was dead”.

She said her brother had a positive impact on all who met him. “It is shocking to us that a self-admitted psychiatric patient would be able to take his own life within the very walls of a HSE mental hospital”, said Ms Collins.

Coroner Eamon MacGowan heard that Mr Collins was admitted to the unit on Saturday, April 1st when he presented with extreme anxiety, insomnia and chaotic thinking.

There was evidence that six years previously he had made a suicide attempt and had been treated in St Patrick’s Hospital in Dublin . On admission to the St Columba’s unit he had been allocated a single room “for the best of intentions”, according to psychiatric nurse Gerry McGlinchey .

Mr Collins told staff in St Columba’s that he had been put on anti-depressants before and they had made him suicidal.

Another nurse, Sean Gilmartin, told the coroner that when he went into Mr Collins’s room at 8.30am on the day he died, he found the young man sitting on the floor with his back to the wall. He said he had taken 10 to 12 sleeping tablets at 5am as he had wanted “to end it all”. He had an empty box which had contained 21 tablets which had been prescribed by his GP.

The post mortem showed that there was only “traces” of this sleeping tablet in the man’s system.

Consultant psychatrist Dr Edmund O’Mahoney said the young man told him he had been desperate to get some sleep and he did not want to end his life. He had told staff he had not slept for four days, the jury heard.

Mr O’Grady pointed out that the date the box was March 31st which suggested that 21 tablets had been taken in three days.

Mr O’Grady said the HSE had already apologised to the family for its failings in this case.

Dr Joanna Perlinska the first clinician to examine the deceased said he was “an amazing guy, full of energy”. She said she had been stunned by his death and could not imagine how the family felt.

* If you are affected by any of the issues raised, you can contact Samaritans’ free helpline on 116-123, text 087-2609090 or email jo@samaritans.ie; or call the free Pieta House 24-hour suicide helpline on 1800-247247 or text HELP to 51444.