Mental health: Craigavon Hospital patient suicide investigated

Seán Boyle with his mother Sinéad Boyle

Seán Boyle, a music fan who was planning a career in farming, was 24 years old when he died after attempting suicide in June 2020.

His death happened days after he was admitted to the Bluestone psychiatric unit at Craigavon Area Hospital in County Armagh.

The Southern Health Trust, which runs the unit, has offered its condolences to Mr Boyle's family.

The trust was at one point being investigated for corporate manslaughter.

Warning: This article includes discussion of suicide, which some readers may find distressing.

Seán's story

Seán had a history of self-harm and suicide attempts, according to his mother Sinéad Boyle, who is from Newry in County Down.

She told BBC News NI's Spotlight programme that he had used drugs since he was a teenager and because of this had been in hospital many times.

He had also started to believe he was receiving coded messages through the television and radio, she explained.

"I remember thinking, OK, this is bigger than me - I need someone who understands what's going on chemically in his brain and understands his behaviour'," Sinéad said.

"So I made the fatal call to mental health services in Newry."

What happened?

Seán was admitted to the Bluestone unit on 27 May 2020 at 17:30.

He was assessed by two doctors, who decided he should be temporarily detained.

Spotlight has seen the paperwork signed by the doctors, in which they offered an insight into Seán's mental health at the time and their belief that he was at risk of harming himself.

The programme has also seen a copy of an investigation report commissioned by the Southern Trust following his death, which happened at the beginning of the Covid-19 pandemic.

It found the patient was uneasy interacting with staff wearing full personal protective equipment and he initially refused a Covid-19 test.

Seán was subsequently confined to a four-bedroom corridor away from most other patients.

Bluestone psychiatric unit at Craigavon Area Hospital

The report said that during the night a member of the nursing staff took away Seán's belt, locking it in a bedside cabinet, despite more senior clinicians previously allowing him to keep it.

Later, when he asked for it, the same member of staff gave it back to him.

The staff member felt they had "no basis beyond persuasion to refuse its return", according to the investigation, despite Seán having been deemed at risk of harming himself by doctors when he was admitted.

Seán was confined to this four bedroom corridor

Seán last appears on a CCTV camera at the ward at 14:48 on May 28, about 21 hours after he arrived at the hospital.

Just over an hour later, by 15:53, Seán was found unresponsive by the clinical team sent to assess him.

He had tried to kill himself and died three days later in intensive care.

Concerns raised

A letter from the Department of Health to the Southern Trust following the death raised concerns about another patient who had attempted suicide at Bluestone seven months earlier.

Like Seán they had tried to use a window fixture, leading to such fixtures being changed in another part of the hospital, but not on Seán's ward.

Collapsible window fixtures have now been installed throughout Bluestone.

Speaking to Spotlight, Seán's mother, Sinéad, believes his death could have been prevented.

"I thought he was in a place of safety," she said.

"I had a belief they had the answers, they had the expertise, they had what I didn't have to help him."

Information and support

If you are experiencing issues with mental health or self-harm, details of help and support are available here.

The staff member who removed Seán's belt later said it was taken from him as he was deemed a risk to staff and other patients.

That member of the nursing staff based their assessment on reports of his behaviour from before he was an inpatient.

The investigation report commissioned by the Trust does not specify what these reports were.

The investigation also does not state why staff no longer considered Seán a risk when his belt was returned.

The investigators said they had no criticism of the staff member who returned the belt to Seán, but recommended the Trust develop a clear policy on the removal or restriction of patients' personal items.

Fifteen minute checks

The report also uncovered another issue, which led police to begin investigating the apparent falsification of a record around Seán's care.

According to Southern Trust policy, Seán and other patients were supposed to be checked during every 15-minute period.

Seán Boyle died on 1 June 2020

These checks should be recorded to ensure patients are being properly cared for, but the report said it "could not be confident Seán was observed as prescribed within every 15-minute period as written on the observation sheet".

In a written statement and an interview, another staff member said they had seen Seán walking from the corridor into his bedroom at 15:40, less than 15 minutes before he was found unresponsive.

The ward's CCTV footage, retained at the request of police, showed Seán had not left his bedroom since 14:48, nearly an hour earlier.

During police interview, the staff member conceded they had made a mistake.

Disciplinary action

Dr Brodie Paterson, an expert in the treatment of mental health patients, has seen a copy of the report into Seán's care.

"There is a potential that if a member of staff had turned up, they could have interrupted his preparations, they could have picked up on the change in mood, it could have been prevented," he said.

"There's lots of 'ifs' in that, but in reality, none of it had the possibility of happening because the nurse didn't turn up."

Spotlight understands the staff member faced disciplinary action and was suspended for six months.

According to police notes seen by the programme they were recorded as being left deeply impacted by the incident.

'The process has been so long, so slow' - Sinéad Boyle

In a statement, the Southern Trust said Seán's death was the subject of a Coroner's investigation, in which it is fully engaged, along with a police investigation.

It told the BBC it was unable to comment on specific issues as a result.

However, a spokesperson said the Trust had implemented a range of measures at Bluestone to improve the quality and safety of care.

Police notes seen by Spotlight suggest it is unlikely anyone will be prosecuted.

Three years after her son's death, Sinéad Boyle said she has questions around his death which have yet to be fully answered.

"This process has been so long, so slow," she said. "I can't change what happened, I can't change him not being here.

"But the sad part about this is it didn't need to be this way."

Watch Spotlight: Seán's Story - Death on the Ward on iPlayer

If you are affected by issues raised in this article, help and support is available via the BBC Action Line.