Hospital failed to remove ligature risk after previous suicide

An inquest at Galway Coroner’s Court heard that Tara Coyne from Roundstone died by suicide five hours after her voluntary admission to the AAMHU on July 14, 2020 – using an ensuite bathroom door which had been identified as a ligature risk following the death of a patient in similar circumstances just over five months earlier.

In a statement read out at the opening of the inquest, counsel for Saolta, Luán Ó Braonáin SC, said UHG and the Saolta Hospitals Group wished to “sincerely and unreservedly apologise” to the Coyne family “for failing to take remedial in relation to the ensuite doors in a more timely fashion”.

In evidence to the inquest, Registered Proprietor of the AAMHU Stewart Jackson said that following the death by hanging of another patient using the ensuite door of his single occupancy room in January 2020, a review was undertaken.

As the AAMHU at UHG was a new building, only opened for use in 2018, the problem was elevated to its design team and HSE West Estates.

“With regret, remedial action was not finalised until after the tragic death of Tara,” he said.

Coroner for West Galway, Ciarán MacLoughlin, was told that the replacement of the doors – of which there were more than 50 throughout the unit – got underway within days of Ms Coyne’s death.

Solicitor for the Coyne family, Ciarán Damien Tansey, questioned why, if remedial work to replace the doors could be carried out just one week after Tara’s death, it could not have been done in January.

Photo shows the Acute Adult Mental Health Unit at UHG.

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