‘Karl should have been safe in a mental hospital’

Karl Collins checked himself into Sligo’s St Columba’s mental health hospital at 9am on April 1, 2017. He was suffering from extreme anxiety and catastrophic thinking. Within 54 hours, he was dead.

An inquest into Karl Collins’s death was held at Sligo Coroner’s Court on Monday, November 12th. A jury of five men and two women returned a verdict of death by suicide.

It was a preventable suicide, in the view of the Collins family.

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Karl Collins came from a large family. His parents, Irene and Pat, had six children: Aisling, Roslyn, John, Jennifer, Maria and Karl – the youngest. Pat died after a battle with cancer in 2015. The family home is in Sutton, north county Dublin, close to Howth Head.

“Karl was a joy to be around. He lit up a room and you always knew you would have fun in his presence,” says Aisling.

Karl was a snowboarder, kayaker, fully-licensed coach driver, activity instructor, rock climber, and trained mountain leader. He had a degree in video and film and taught children with autism how to surf.

He had nine nephews and nieces. “They idolised their uncle Karl, and he adored them,” says Roslyn. “He had the most magical and beautiful imagination. A few years ago, he carved a magic wand for his niece’s birthday. He told her that he had climbed a mountain, plucked the tail of a phoenix and embedded it into the wand. He was so much fun. He put everything he had into everything he did.”

But Karl was also fighting a battle with mental health. Six years before he took his own life, Karl made the only other suicide attempt his family are aware of.

He was aware of his issues. He went for cognitive behavioural therapy. He spoke. And he went looking for help

“He was living at home at the time, and he was suffering with anxiety and insomnia,” Maria recalls. “He disappeared in the middle of the night. In the pitch black, we went out, calling his name. We found him wandering. Later, he told us that hearing his name being called had snapped him back.

“We brought him to Beaumont A&E and then he was signed into St Ita’s psychiatric hospital. After a few weeks, we had him moved to St Patrick’s mental health hospital, and they were brilliant.” He spent six weeks there and was keen to stay well.

“Karl did everything you are supposed to do,” says Maria. “He ate healthy. He made himself kale smoothies for breakfast. He was active and outdoors. He meditated.

“He was aware of his issues. He went for cognitive behavioural therapy. He spoke. And he went looking for help. He followed the rulebook for mental health. He should have been safe in a mental hospital.”

Shortly before his death, Karl had moved into a house with his partner. “He was just unwell,” says Jennifer Collins. “He loved life: people can be suicidal but it doesn’t mean that they want to die. He needed help.

“In January, a few months before he died, he came over to talk to me. We went to the beach, with my kids running around, and he told me that was sad and he was crying. He was very open about it and always maintained a conversation with us.”

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On the morning of April 3rd, Karl told staff that at St Columba’s mental health hospital in Sligo that he had taken between 10 and 12 anti-insomnia tablets, which he had brought into the hospital. When the nurse found him on the floor, he said: “I wanted to end it all.”

He said he hadn’t slept in days, and that he had taken at least 10 times the maximum daily dose. Karl was given quetiapine, an antipsychotic drug, and he went for breakfast with the other patients.

At around 11am, Karl was seen by consultant psychiatrist Dr Edmund O’Mahoney. “He seemed anxious and restless, but articulate,” O’Mahoney told the inquest. “He said he had f**ked up his life and couldn’t think straight because he couldn’t sleep.”

Karl wanted medication to calm his mind and was given diazepam, an anti-anxiety drug. He went to the canteen between 12.30pm and 1pm and was given a further 5mg of diazepam.

His partner arrived to see him at 1.30pm. It was then that a nurse found him in his bedroom and raised the alarm. Karl was taken by ambulance to Sligo General Hospital where he was pronounced dead at 2.33pm.

St Columba's is not particularly unusual. Nationwide, the commission recorded 29 deaths by suspected suicide between 2015 and 2017

The HSE has apologised to the Collins family for its failings in the case. Most significant among these is that there were a number of “ligature points” – fixtures and fittings which could support a noose – at the hospital.

As far back as 2008, the Mental Health Commission found that the hospital was "not fit for purpose". Inspectors continued to raise this concern right up to the latest published report in 2017. From 2014, successive commission reports urged the hospital to deal with the problem of ligature points.

The Irish Times understands that another suspected suicide took place at the hospital in May 2018, just over a year after Karl's death. The HSE has confirmed that an apology has been made to the family of the man and that an investigation is ongoing into this incident. In the same month, an audit found that there were still 365 ligature points in the hospital. Within 12 weeks of that audit, these were reduced to 247, with no high-risk ligatures remaining in place.

St Columba’s is not particularly unusual. Nationwide, the commission recorded 29 deaths by suspected suicide between 2015 and 2017.

No staff member accompanied Karl in the ambulance, which upset his family; the HSE is to consider a recommendation that staff maintain a presence with the patient in emergency circumstances.

A series of doctors were questioned by barrister Keith O’Grady, representing the Collins family, as to why Karl had not been placed under high observation after he told staff he had taken tablets that morning and felt that he “wanted to end it all”, particularly considering he had made a previous suicide attempt. Karl had also told staff that, when he was prescribed one of the same medications six years previously, it had made him feel suicidal.

In response, O’Mahoney said that Karl was not on an excessive amount of medication and that they did not assess him as a suicide risk, partially because of his demeanour, positive interactions with staff and apparent willingness to get better.

The family point out that Karl’s previous clinical notes from St Patrick’s were not requested by St Columba’s. They say they would like to see the HSE develop a centralised system which would enable staff to share patient notes.

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At various points between 2008 and 2016, the Mental Health Commission identified multiple issues with both the building and the administration of St Columba’s. These includes problems with risk management, clinical governance, quality of care plans, the mix of staff skills and serious staff shortages. At the inquest, the hospital admitted that there is a lack of clinical managers on duty at weekends.

One consistent criticism is that the facility is “an old institutional building unsuitable for the delivery of a modern mental health service.” As far back as 2001, the Inspector of Mental Hospitals reported that plans to relocate to a new acute admission unit at Sligo General Hospital were “at an advanced stage” and “it was expected to be commissioned within two years.”

By 2014, when it still hadn’t happened, the Mental Health Commission said that plans to relocate “should be put into effect as soon as possible”.

Planning permission was granted for a new facility in 2015. The construction contract was only approved in September 2018. Funding shortfalls have delayed the project by six months, but the HSE insists it will still open in 2020.

It would have cost potentially €100-€200 to make the room safe

Dr Susan Finnerty, inspector of mental health services with the commission, says that the new building "has not progressed very far at this stage". The HSE has acknowledged that a new unit would greatly reduce the risk of suicide for its patients.

The commission has repeatedly highlighted the problem of ligature points in the hospital and ordered St Columba’s to comply with regulations. The commission has the power to take enforcement action including ordering corrective action or removing a hospital’s registration because it has serious and ongoing concerns about patient safety. The commission instructed St Columba’s to implement a corrective and preventative action plan but, since 2007, five other mental health units have had their registrations removed over serious concerns.

A previous audit of ligature points had identified a particular risk in the room where Karl died. Tomas Murphy, area director of mental health nursing, told the inquest that it would have cost potentially €100-€200 to make the room safe. This figure provoked tears from another of Karl's sisters, Roslyn.

Murphy added that a complete refurbishment to remove all ligature points from the hospital would cost an estimated €4 million. The Irish Times understands that these alterations have not been given the green-light because of the new unit due to open by 2020.

***** The Collins family is critical not only of standards at the hospital but also at the lack of communication from the hospital during Karl’s short stay and how they say they were treated in the aftermath of his death. They are particularly upset at what they say were long gaps in correspondence from the HSE and a lack of clarity as to how their voice could be heard.

After Karl’s death, his mother sent a handwritten letter to the hospital. “He was a lovely son and wonderful brother,” Irene wrote. “I am asking you from the bottom of my heart to put humanity and caring . . . into looking after anybody looking for help in their time of need. I and my family don’t want this to happen [to] any other family. Make changes: check bags on arrival, keep watch over all your care, don’t take anybody for granted . . . invest in mental health.”

“All I wanted is an acknowledgement of what had happened, an assurance that action would be taken to ensure it didn’t happen again, and for them to say sorry,” says Irene. “I asked for a response but it didn’t come for 10 months. We felt ignored.”

Hospital protocol says that families should be provided with verbal and written information on bereavement care services after a death, but the Collins family says there was no aftercare or counselling.

The inquest heard that the response when Karl was found was not adequate

“At a meeting in July, they asked us only if we’d like to talk to Pieta House, but Pieta House were so inundated that it took months to get a bereavement support appointment,” says Maria. “It’s not Pieta House’s fault; they do great work but have limited resources.”

The jury accepted three suggestions made by the Collins family. They recommended that suicide observation systems should be put in place where a previous suicide attempt had been made and if someone was showing signs of suicidal ideation.

The inquest heard that the response when Karl was found was not adequate, and the jury recommended that staff should be continuously trained in emergency response. Finally, it recommended that a client’s next-of-kin be contacted immediately after a suicide attempt.

The Collins family say they are offering support to the staff at the hospital and that they understand the difficulties they must have faced after Karl’s death and on the day of the inquest.

The family say they are hopeful that the HSE will implement the jury’s recommendations in full.

In response to queries from The Irish Times, the HSE apologised again to the family of Karl Collins for "failings in his care".

The HSE statement also said: That works on a new mental-health unit for Sligo/Leitrim would begin on November 19th, with a planned completion date of June 2020; that this would be a modern, purpose-built facility where each client will have their own single en-suite bedroom; that the HSE had a dedicated recurring investment fund of €3 million per year to address ligature points in mental health units; that work to implement the recommendations of the HSE report into Karl Collins‘s death was “ongoing”.

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The Mental Health Commission’s annual report for 2017 says that only 25 per cent of mental health services are compliant with premises regulations, down from 34 per cent in 2016. Inadequate or dirty facilities and the presence of ligature points are the primary cause and, the commission says, there are centres where staff are not mitigating the risks.

An Irish Times analysis of 51 of the most recent commission inspection reports found that 31 centres had significant and often recurring problems with ligature points, while a further seven had made appropriate efforts to mitigate the risks.

At Teach Aisling, a facility in Castlebar, Co Mayo, multiple ligature points had been identified, but the inspection team was informed that funding to deal with the features had been declined in December 2017.

An Irish Times Freedom of Information Act request made previously found that, between 2011 and 2015, 110 people died by suicide or suspicious circumstances besides natural illness or disease.

People have the right to expect that if they, or their loved ones, are in a position where they need the services of an approved centre, those services will at a minimum be structurally safe

“People have the right to expect that if they, or their loved ones, are in a position where they need the services of an approved centre, those services will at a minimum be structurally safe,” says Dr Susan Finnerty. “The HSE is addressing ligature points in many approved centres. However, we are concerned about the speed at which this is happening. That said, I have seen huge improvements in compliance since 2004, including the opening of replacement facilities.”

There are examples of good practice. An Coillín, also in in Castlebar, was not compliant with premises regulations in 2016, but following an audit in 2017, the commission found that structural risks, including ligature points, had been removed or effectively mitigated.

***** “I’m reminded of him every day,” says John of his brother. “I look at the mountains and the snow in Donegal and I’m on the phone to Karl, ‘Wouldn’t it be great to hike here?’ Or I see the waves where he lived in Bundoran, and we’re surfing together. We were planning to go rockclimbing together.

“He travelled all over the world. If he wanted to learn something new, he’d learn it. He liked to take every part of the world around him and create something from it. My little brother lived 10 lives in 30 years.”

Maria says she is completely changed by the tragic loss of Karl’s life. “All the messaging is about talking to people and asking for help. Our brother did this.

“The most troubling and upsetting aspect of his death is that he sought help from the experts but still ended up dying alone and in terrible emotional distress while in their care.”

The inquest has given the family some hope, says Aisling. “We are hopeful that proper pathways will now be put in place for people for people who are struggling, so they can get the help they need.”

* If you are affected by any of the issues raised, you can contact Samaritans’ free helpline on 116-123, text 087-2609090 or email jo@samaritans.ie; or call the free Pieta House 24-hour suicide helpline on 1800-247247 or text HELP to 51444.