Suicidal patient walked unnoticed from Belfast ED shortly before death, coroner finds

By Jonathan McCambridge, Press Association

A suicidal patient walked unnoticed from the emergency department of a Belfast hospital shortly before he died, a coroner has found.

Coroner Anne-Louise Toal said a delay in assessing 50-year-old Stephen Loughead at the Mater Hospital was a “missed opportunity” to potentially prevent his death in March 2024.

The coroner said Loughead from north Belfast should have been assessed by a doctor within 10 minutes, but instead was not called for two hours, by which time he had already left the hospital.

I do find there was a missed opportunity to assess him in a timely manner, which may have prevented his leaving the emergency department on that day and the tragic events that followed

Toal delivered her findings in the inquest at Belfast Coroner’s Court on Tuesday.

She told the court that Loughead had attended Musgrave PSNI station in the early hours of March 15th 2024 and was “clearly experiencing deteriorating mental health”.

The coroner said police took him to the emergency department of the Mater Hospital but did not accompany him inside.

Toal said this action was “contrary to the joint guidance” between police and hospitals.

However, she said the failure to accompany him to ED did not alter the way in which he was treated.

Toal said Loughead waited more than an hour to be triaged, in excess of the target time of 15 minutes.

The coroner said he was correctly triaged as a higher-risk category two patient.

She said he was then brought to wait in a chair beside the nursing station, the only area of the hospital available for observation of higher risk patients.

The coroner said: “Due to staffing pressures, it was not possible to closely monitor him as was appropriate and as a result it is unknown what time he left the department, other than it was after he was last seen at 7.30am.”

Toal said that as Loughead was recognised as being “actively suicidal”, he should then have been seen by a doctor within 10 minutes.

She said: “Due to chronic severe pressures existing within the ED, he was not called for another two hours, by which time he had left the emergency department unnoticed.

“I find the environment in the emergency department and the protracted wait in a noisy and busy unit exacerbated his condition and contributed to his leaving the department before being assessed and this represents a missed opportunity to treat the deceased’s suicidal ideation at that time.”

The coroner said it was not possible for her to say if the patient would have been detained at the hospital if he had been assessed earlier.

But she added: “I do find there was a missed opportunity to assess him in a timely manner, which may have prevented his leaving the emergency department on that day and the tragic events that followed.”

The coroner said emergency department staff are in an “unenviable position”.

She said: “It is a stark reality that, as per the evidence heard by this inquest, was the deceased to walk into the Mater ED today, it is unlikely that anything would change in the way that he was dealt with, not due to a lack of want or care, but due to a chronic lack of resources in a milieu of increasing pressures.”

The coroner said Loughead was last seen by nursing staff at the morning handover at 7.30am and at some point in the next hour he left the hospital and travelled towards the city centre.

She said Loughead was later seen in the River Lagan after 9am.

Despite a rescue operation, Loughead died in the Royal Victoria Hospital from hypoxic brain injury caused by cardiac arrest as a result of drowning.

The coroner passed on her condolences to the family before closing the inquest.

If you have been affected by any of the issues raised in this article, you can freephone the Samaritans 24 hours a day for confidential support at 116 123 or email jo@samaritans.org.  

You can also freephone the national Bereavement Support Line run by the HSE and Irish Hospice Foundation at 1800-80 70 77 (Monday-Friday 10am-1pm), and the contact information for a range of mental health supports is available at mentalhealthireland.ie/get-support/. 

In the case of an emergency, or if you or someone you know is at risk of suicide or self-harm, dial 999/112.