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Coroner calls for public inquiry after death of Ballina man at mental health hospital

Coroner calls for public inquiry after tragic death

Family of 39-year-old Ballina man question care

Anton McNulty & Trevor Quinn

The Coroner for Mayo South, Mr John O’Dwyer, has called for a public inquiry into the death of a Ballina man at Mayo Mental Health Hospital after his family stated that it was their belief that the father of four did not get the necessary care to ensure he was kept safe.
Mr John Greham, 26 Brusna Court, Ballina was found dead in the toilets of the hospital in Castlebar in the early hours of July 4, 2010 while he was a patient in the Mayo Mental Health Hospital. He took his own life.
The 39-year-old had been admitted as an involuntary patient under the Mental Health Act on June 29, 2010, by Gardaí after his family reported that he was considering taking his own life.
His family believe there are serious questions which need to be answered in relation to the care which he received prior to his death. They said that they envisaged that by safely admitting the single man to the unit that he would have been prevented from taking his own life.
Speaking last Wednesday during a three day inquest in to Mr Greham’s death, Mr O’Dwyer said he felt it was in the public interest that he requested the Inspector of Mental Health Services to undertake a public inquiry in to the death of the deceased.
Mr Greham was assessed by Consultant Psychiatrist, Dr Orfhlaith McTigue, who told the inquest in Castlebar that he had denied any suicidal thoughts or plans and said he did not want to be hospitalised. She detained him under the Mental Health Act but felt he did not require special one-to-one observations. However, she recommended he be nursed in his night attire on 30 minute observations.
Nevertheless, the man’s family felt that the hospital had not taken all their concerns into consideration and felt he had told the hospital staff what they wanted to hear. They argued that they had stressed how Mr Greham would deny anything and was an ‘intelligent’ person who would tell hospital staff what they wanted to hear.
Dr McTigue said she had taken everything the family had said on board, but had still felt that what the patient had told her was truthful, and she did not believe he was an immediate suicide risk. She said she was still happy with the assessment she made.
At 12.30am on the morning of July 4 John Greham was found to be missing from his room. A search was undertaken by Staff Nurse John McNamara who found Mr Grehan unconscious in the toilet with a green clothes belt around his neck which asphyxiated him after hanging from a door in the toilet area. Efforts at resuscitation were unsuccessful. How the belt came into Mr Greham’s hands was never established but the inquest found it was not his property.
Dr Deirdre Garvey, Consultant Psychiatrist for the Ballina sector, told the inquest that it would be reasonable for the family to hope a loved one would not have the opportunity to take their life while in the hospital.

When asked by the family if the unit was a safe place for a person on a 30-minute observation period, she replied that they try to make the unit as ‘safe as possible’. She stressed that staffing levels were not a problem in 2010 but there is a current issue with staffing levels.
The family said that they had put him in the unit because they thought it would be a safe place for him to be.
Following the death, an inquiry was carried out by the hospital. The inquiry found that the fatal events of what happened could not have been predicted by the duty staff at the time. When it was put to Dr Ciarán Smyth, Acting Clinical Director at Mayo Mental Health Services, by Mr John O’Dwyer, Coroner for South Mayo, that they had let the patient down, he responded that it was not an outcome they had envisaged.
Dr Smyth agreed that the family had done the right thing to refer him to the Mental Health Unit but stressed that nothing was 100 per cent safe.
“Even on one-on-one observation, a detainee can orchestrate a situation which can undermine their safety, and there is no guarantee of total and absolute safety. Placing a person in a padded cell may guarantee 100 per cent safety, but that would be counter productive,” he said.
Dr Smyth told the family that risk assessment was a clinical assessment which was subjective and not ‘infallible’.
The inquest had been part heard last September, when it was revealed that the Garda investigation into the death had been frustrated by hospital staff. Mr O’Dwyer said that his position as a Coroner was to find the truth, but that everything that could be done to frustrate this was done.
Dr Smyth denied that they were covering up anything and explained that they had received legal advice to only provide a statement for a coroner’s investigation and not for a criminal investigation.