Serious concerns over practices and procedures in the psychiatric unit of Letterkenny Hospital have been raised.
It follows an inquest into the death of Fintown man Sean Quinn heard how his family had warned medical staff that he was not well enough to be discharged.
Mr Quinn, a 63-year-old father-of-four from Darraghan Beag, Fintown, was an inpatient at the time and on temporary leave when he was found dead in a nearby river on the morning of March 16, 2013.
Just the day before, Mr Quinn – who had deliberately overdosed on two occasions in the weeks leading up to his death – had been allowed home for the St Patrick’s weekend in spite of his family’s unease.
His family also raised serious concerns about his medication, telling the inquest that Mr Quinn had twice been prescribed SSRIs (Selective Serotonin Reuptake Inhibitors) without being informed of the potential side effects.
The coroner for Donegal, Dr Denis McCauley, issued four recommendations at the close of the inquest aimed at avoiding a repeat of the tragic circumstances that befell Mr Quinn.
At the outset of proceedings, Ms Patricia McCallum BL, counsel for the Quinn family, said her clients wished to formally note their objection to the coroner’s decision to proceed with the inquest without a jury.
“They are deeply disappointed not to have a jury,” Ms McCallum said. “They feel that a jury would have brought an objective insight in respect of the matter and they feel they have been deprived of that.”
Ms McCallum, instructed by Mr Cormac Hartnett of Hartnett Hayes Solicitors, appeared for the Quinn family while Letterkenny University Hospital was represented by barrister Mr Rory White, instructed by Francis Gaughan of Hegarty and Armstrong Solicitors.
A spokesperson said that family members attended the inquest “under protest”.
The Quinn family said they want “transparency and accountability” into the death of their husband and father.
They also argue that, despite expert medical evidence suggesting his death was linked to prescription-induced deterioration, these reports were not admitted into the inquest record.
Ms Ann Quinn told how her husband, with whom she had four children, worked on the train in Fintown and sold vegetables in the locality. He was in good health until he contracted pneumonia and had a prostate issue. In late 2012 and early 2013, he began to experience mental health issues.
Ms Quinn recalled how the family was advised at one stage that the psychiatric unit was full and there was no bed for her husband.
Following his admission, Mr Quinn was allowed out for an hour’s leave and the pair went for a cup of tea in Letterkenny. However, after “two mouthfuls of tea” he asked to go back to the unit and medics were advised of what had happened following their return.
“I was so worried,” Ms Quinn said. “I didn’t want him to be coming home.”
Just three days later, Mr Quinn was released home for a weekend leave and the next morning was found dead in a river close to his family home.
Ms Quinn raised several issues with her interactions with medical staff.
During one meeting, she recalled saying that her husband wasn’t well enough to be at home when one medic turned to her husband and said: “We will have a man-to-man talk. How do you feel Sean”?
She outlined that her husband said “I am no better from the day I came in” at that point and she told Dr McCauley that she was “not at all” happy for her husband to be given a weekend release.
Prior to these episodes, she said her husband was a “very active and outgoing person” who “loved the farm” and “went to all the football matches”.
She told how, after her husband overdosed on the substance, a doctor asked him: “Why did you drink weedkiller?” and later added: “There’ll be no weeds in your stomach tonight, Mr Quinn.”
She told nurses of this and was advised to make a complaint.
Ms Quinn told the inquest: “He was in a bad enough state without hearing some professional coming out with such a statement.”
Ms Martina Quinn, the deceased’s daughter, heartbreakingly recalled how she found her father’s body.
She said she felt that her father was not conveying how he really felt and was “telling hospital staff what they wanted to hear”.
“The episodes before he was admitted, they were so impulsive and that wasn’t dad,” she said.
Regarding her father being let out on weekend leave from the psychiatric unit, she added: “Initially it was talked about to come home for a couple of hours and he’d get back in the afternoon. It changed on the Thursday where they were talking about the weekend leave. That was concerning. We were worried as to what we would do.”
A doctor pronounced Mr Quinn dead at 11.45am on March 16, 2013 and, after his remains were escorted to the mortuary, a post-mortem confirmed that he died of drowning. There were other incidental findings that had no bearing on the cause of death, the post-mortem reported.
Dr Colin O’Donnell, a consultant psychiatrist who is the current clinical director of the unit, was called. While he did not have any interaction with Mr Quinn, the two main treating doctors were not available to the inquest as they are not in the country.
Medical notes outlined how Mr Quinn was prescribed prozac by his GP in February 2013 and was diagnosed with an adjustment disorder on February 16 after presenting to the emergency department at Letterkenny Hospital.
Mr Quinn had two episodes of self-harm when he overdosed, including on antidepressant tablets.
He had been on prozac for about eight days – but that would mean it “hadn’t reached a steady state” in his system Dr O’Donnell said – before being moved onto sertraline and admitted to the psychiatric unit.
The inquest heard that Mr Quinn had lost sheep and an uncle had died, which were said to be ‘stressors’ attributed to his low mood around the same period.
On the day before his death, a doctor completed a clinical risk assessment and said Mr Quinn was not clinically depressed. The doctor said he could leave from Friday-Monday, but could return earlier if needed.
“With the benefits of hindsight and looking back, I do believe that he probably was suffering a severe depressive episode,” Dr O’Donnell said.
It would be his common practice to warn people of side effects of SSRIs, Dr O’Donnell said, remarking that there could be a delay in the effect of some antidepressants.
He said that medical risk assessment forms are “used more now” and added: “They are routinely used and updated regularly”
A nurse, Mairead Gallen, who said Mr Quinn was “very quiet and hard to engage” and described him as “guarded”, recalled in a deposition how Ms Quinn conveyed concerns and she advised her to speak with the doctor.
Nurse Noreen McLaughlin, referring to notes from the time in a deposition, said that Mr Quinn was visited by his wife and availed of a one hour spell out of the unit, which he “appeared to enjoy same”.
The following day, Mr Quinn attended a therapeutic programme and on that day, March 14, 2013, she recalled taking a phone call from Ms Quinn, who said that her husband indicated that if he went on leave from the unit he “may not return”.
Ms McLaughlin said she approached Mr Quinn about what he said and he admitted that his mood hadn’t improved since entering the unit.
She said a weekly review took place on Friday, March 15, 2013 and Mr Quinn advised that his mood had improved.
The nurse remarked that Ms Quinn was “agreeable” to the home visit, but this had been strongly disputed by Mr Quinn’s widow in her deposition and answers to the coroner and the two barristers.
Asked some questions by Dr McCauley, Ms McLaughlin said she had “very, very little” recollection and would “have to go with whatever is in the notes”.
Professor Ciaran Mulholland, a consultant psychiatrist, was called as a coroner’s witness to the inquest.
He spoke about the use of and effectiveness of SSRIs and outlined that it was important to explain common side effects to patients when being prescribed such medication.
Mr White asked if side effects were as well understood in 2013 and Professor Mulholland said that there was a turning point in awareness “probably 10 years earlier” and the practice should have been to warn of those side effects in 2013.
Professor Mulholland told Ms McCallum that there was a “black box warning” in relation to SSRIs from around 2005. The black box warning – a boldfaced text that appears at the beginning of the package insert – is the most severe warning the FDA (the US Food and Drug Administration) can place on a drug short of an outright ban.
He said if side effects were discussed with patients then at the “very least” it should be noted, but that it was best practice to say what you mean. Professor Mulholland added that it was “very important” that family members are listened to prior to the discharge of a patient.
Dr McCauley found that the cause of Mr Quinn’s death was drowning and he returned a narrative verdict: Mr Quinn attended his GP in February 2013 and was prescribed an SSRI. He then had two episodes of self-harming and was eventually admitted to the psychiatric unit at Letterkenny Hospital. He was granted temporary leave on 15th March, 2013 and on the 16th March 2013 he died via drowning.
Dr McCauley issued four riders, aimed at improving care for psychiatric patients:
1 – That the use of SSRI medications in patients be periodically reviewed to assess whether they are giving a benefit or to rule out side effects.
2 – That a full and formal risk assessment is carried out which specifically includes the views of family members prior to the discharge or temporary release of patients.
3 – That every effort should be made to otherwise ensure that a multi-disciplinary team is present to maximise the benefits to the patient.
4 – While issuing a prescription of SSRIs, the common side effects are explained to the patient. In the event that the patient is unable to register and formulate this information, then this should be explained to an appropriate relative/next of kin.
The Quinn family, through its legal team, had sought a finding of death by misadventure.
Ms McCallum said that the Quinn family had lived with someone who was “well” until very close to his death.
She pointed out that Mr Quinn had two episodes of self-harming after being first prescribed SSRIs and said it was “difficult to understand” how he was released over a bank holiday weekend when he could have been held under section 23 of the Mental Health Act, 2001 at the same time.
“They (the Quinn family) feel that had the risk of SSRIs been made available, the family may have been more informed,” Ms McCallum said.
“Had he not been released on a temporary release, he may have been in a more secure accommodation and what happened may not have happened.”
Ms McCallum said that Mr Quinn was still “under the care of the medical team” at the time of his death as his bed was “there waiting on him”.
Mr White said the evidence didn’t support the test for medical misadventure – an intended act with an unintended consequence. He said there could be an association but not a causation,
However, Ms McCallum added: “I want to be very clear about this: He was an inpatient of the hospital and was under the care of the hospital. Leaving aside the SSRI, there was an intended action to release the man and the unintended reaction had to be his death.”
She said there was: uncontested evidence that a temporary discharge did not go well; uncontested evidence that Ms Quinn voiced concerns on at least two occasions prior to her husband’s temporary discharge; 3 – and there was a “jump for no particular reason” to him being released for an entire weekend.
Ms McCallum said: “There was no evident decision making process or there is a gap in the decision-making process.”
If you have been affected by any of the issues mentioned in this article, you can contact the following helplines
Samaritans 116 123 or email jo@samaritans.org; Text About It – text HELLO to 50808; Aware 1800 804848; Pieta House 1800 247247 or text HELP to 51444. A range of mental health supports is available at mentalhealthireland.ie
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