Patient's death in NI mental health unit preventable, inquest rules

Davin Corrigan's family say they always knew his death could have been prevented

The family of a patient who died while detained at mental health unit in Londonderry has welcomed the findings of an inquest after it ruled his death was preventable.

Davin Corrigan, 25, died by suicide at the Grangewood unit in November 2018.

Failings and missed opportunities by the Western Trust, the RQIA and the Northern Ireland Adverse Incident Centre (NIAIC) led to unnecessary risks for patients, the coroner ruled.

The Western Trust has apologised.

In a statement outside Laganside Courts in Belfast, the family thanked the coroner, adding it was "something that they always knew".

Increased risk

"One of the most shocking findings is that changes should have been made as far back as 2015, three years before Davin's death," Mr Corrigan's mother Aisling said.

There had been a number of suicides and attempted suicides in similar circumstances on Carrick ward - where Mr Corrigan died - which dated back to 2013, the inquest heard.

The coroner said there were serious failings by ward staff and management in recording, reporting and escalating these incidents, which led to increased risk for both patients and staff at the hospital.

An independent report in 2020 found there were failings "at every level" in the Western Health and Social Care Trust.

Mr Corrigan's family said he was extremely popular, had an "infectious personality" and would "light up a room".

But in the period before his death he became more and more withdrawn, staying in his room, refusing meals and seeking his medication early.

He had self-harmed on at least two occasions, was hearing voices and had said he no longer wanted to live, the inquest heard.

His mother said it was "like watching someone die".

But despite this, no safety plan was in put place to protect him, even though staff were aware he was a risk to himself.

The RQIA failed to inspect the Grangewood unit after Davin Corrigan died, the inquest heard

Concerns raised by the Regulation and Quality Improvement Authority (RQIA) about the type of door used in patient ensuite bathrooms, which posed a ligature risk, were not acted upon quickly enough, the coroner said.

A wait of two years while a new, safer door was being developed, was "unacceptable", the coroner added, while the RQIA, which has responsibility for monitoring and inspecting health and social care services in Northern Ireland, failed to follow up on its recommendation that doors be replaced.

During this two-year period, the doors were a factor in three serious incidents, including Mr Corrigan's death.

The court heard the RQIA failed to inspect the Grangewood unit after Mr Corrigan died, despite a complaint from his mother.

Substantially changed procedures

The RQIA praised the "courage, determination and resilience" of Mr Corrigan's family in "pursuing the changes needed to prevent similar tragic events".

The regulator said it has substantially changed its procedures for inspection of mental health hospitals and wards following Mr Corrigan's death.

In a statement, the Western Trust said it "wholeheartedly accepts the failings" regarding Mr Corrigan's care and gave its condolences to his family.

It said risk management procedures have been put in place since his death "to help prevent further reoccurrences of such incidents".

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